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ANALYSIS OF THE URINE, 



WITH SPECIAL REFERENCE TO THE 



DISEASES OF THE GENITO-URINARY 

ORGANS. 



BY 

Ef B. HOFMANN, 

PBOFESBOB IN THE UNIVEB8ITY OF GBATZ, 
AND 

R. ULTZMANN, 

DOCENT IN THE TT N I V E B 8 I T Y OP VIENNA. 



TRANSLATED BY 

T. BAETON BEUNE, A.M., M.D., 

BESIDBNT PHYBICIAN MAEYLAND TJNIVEB8ITY HOSPITAL, 
AND 

H. HOLBKOOK CURTIS, Ph. B. 



V. . ' 



NEW YORK.: 
D. APPLETON AND COMPANY, 

549 AND 551 BROADWAY. 

1879. 



lr 




COPTEIGHT BY 

D. APPLETON AND COMPANY, 

1879. 



TEANSLATOES 1 PEEFACE. 



We liave undertaken the translation of this little 
work, hoping that it will supply a need which has 
been long felt by American students and physicians. 
"We do not know of a single work in the English 
language where, in a concise form, so many valuable 
suggestions and practical hints are offered, both as 
regards analysis and diagnosis. The book does not 
pretend to be an elaborate and exhaustive treatise on 
the diseases of the genito-urinary organs; such an 
•idea is at once precluded by the title and size of 
the work. It merely claims to contain all that is 
necessary for the student and practicing physician. 

The merit of the work is sufficiently attested by 
the popularity it already enjoys in Germany and Aus- 
tria, and the fact of its having appeared in three 
languages during the year of its publication. 



4 TRANSLATORS' PREFACE. 

While making no claims to elegance of translation, 
we have endeavored to be faithful to the original text, 
and at the same time to explain the methods of pro- 
cedure so clearly, that without other aids the student 
may be able to perfect himself in the rapid analysis 
of the urine, and furthermore to draw his conclusions 
from the same. The added plates, which do not appear 
in the German edition, are principally taken from 
"Ultzmann and Hofmann's Atlas der physiologischen 
und pathologischen Harnsedimente," and from photo- 
graphs kindly furnished by Dr. Ultzmann, under whose 
supervision we have performed our work. 

The Translators. 

Vienna, December 20, 1878. 



TABLE OF CONTENTS. 



PAGE 

Introduction 9 



CHAPTER I. 

Histology of the Urinary Organs 15 

1. The Kidneys 15 

Urinary Tubules 16 

Blood-vessels of the Kidney 20 

Nerves of the Kidney 22 

2. The Excretory Ducts 22 

Ureters, Kidney-pelvis, and Calices . . . . . . . 22 

Urinary Bladder . . " 23 

Male Urethra 24 

Female Urethra 25 



CHAPTER II. 

The Excretion of the Urine 26 

CHAPTER in. 

The Urine 31 

A. A General Description 31 

B. Physical Characteristics . . 32 

1. Amount 32 

2. Specific Gravity 33 

3. Solid Ingredients . 34 

4. Consistence 37 

5. Color 38 

6. Transparency and Fluorescence 41 

7. Odor 42 

8. Reaction 42 



6 TABLE OF CONTENTS. 

PAGB 

C. Chemical Composition 44 

a. Normal Organic Constituents .44 

1. Urea 45 

2. Uric Acid ... 52 

3. Coloring Matters . . . 59 

a. Urobiline 59 

0. Urine-Indican 61 

4. Other Normal Organic Constituents 66 

b. Normal Inorganic Constituents . . . . . . 68 

1. Chlorides 68 

2. Phosphates 71 

a. Earthy Phosphates 72 

/3. Alkali Phosphates 75 

3. Sulphates 77 

c. Abnormal Constituents 79 

1. Albumen ; . . ... , .79 

Nitric Acid Test 82 

Boiling Test 84 

2. Sugar 89 

Heller's Test . ' . . ' .'■'■. . . . . .90 

Trommer's Test 91 

Bottger's Test 92 

Vogel's Method of Approximative Determination . . 95 

Inosite 96 

3. Leucine and Tyrosine . 97 

4. Abnormal Coloring Matters . ' .98 

a. Uroerythrine 98 

j8. Plant-coloring Matters . . 100 

7. Blood-coloring Matters ■ . . 100 

8. Biliary Coloring Matters . . . . . . .103 

5. The Bile Acids 107 

6. Carbonate of Ammonium . .109 

7. Sulphuretted Hydrogen . . Ill 

8. Accidental Constituents . . . . . . . .112 

D. The Sediment 114 

Urine Fermentation . . . . . . . . .114 

Classification of the Sediment ,. 117 

a. The Unorganized Sediment . 119 

1. Urates 119 

2. Urate of Ammonium 121 

3. Uric Acid 122 

4. Calcium Oxalate . 124 

5. Cystine 125 

6. Leucine and Tyrosine 127 

7. Fat . . . . . . . . . . 128 

8. Earthy Phosphates . . . . . " . . .129 

9. Magnesium Phosphates . . . . . . 131 

10. Triple Phosphates . . . '. . . . .132 

11. Calcium Carbonate 123 



TABLE OF CONTENTS. 



b. The Organized Sediment 

1. Mucus . 

2. Epithelium 

3. Pus-corpuscles (Donne's Test) 

4. Blood-corpuscles 

5. Cylinders 

6. Parasites . 

7. Spermatozoa . 

8. Cancer Elements 

9. Entozoa 



PAGE 

133 

133 
135 
139 
139 
141 
147 
151 
152 
154 



RECAPITULATION. 

Concretions 155 

Analysis of the Concretions 158 

CHAPTER IY. 

Reagents and Apparatus for the Approximative Determination of the 

Urine Constituents . . ... . . . . . .163 

Reagents 163 

Apparatus 164 

CHAPTER V. 

Quantitative Determination of a few of the Constituents of the Urine. 166 

I. "Estimation of the Degree of Acidity 167 

II. Estimation of the Solid Matters 167 

III. Estimation of Urea . . . 168 

1. Liebig's Method . 168 

2. Bunsen's Method 174 

3. Knop-Hiifner's 175 

IV. Determination of Uric Acid 176 

V. Determination of Creatinine 178 

VI. Determination of the Total Amount of Nitrogen 179 

VII. Determination of Albumen 181 

VIII. Determination of Sugar 181 

1. Fehling's Method 181 

2. Knapp's Method . . . . 184 

IX. Determination of Chlorine . . 184 

X. Determination of Phosphoric Acid . . . . . . .186 

XI. Determination of Sulphuric Acid 188 



CHAPTER VI. 

Key to the Approximative Analysis of the Urine 190 

Chemical Investigation 190 

A. Nitric Acid . 190 

B. Heat Test ........... 191 



8 TABLE OF CONTENTS. 

PAGE 

C. Test for Noftnal Coloring Matters of the Urine 193 

D. Test for Normal Inorganic Salts of the Urine 193 

E. Test for Abnormal Matters . .193 

F. Investigation of the Sediment . . . .. . . 193 

CHAPTER VII. 

General Diagnosis . . . . 198 

CHAPTER VIII. 

Diagnosis of the Diseases of the Urinary Apparatus .... 207 

A. True Albuminuria 208 

1. Hyperemia of the Kidney „ 208 

2. Parenchymatous Nephritis 211 

a. Acute Parenchymatous Nephritis . . . . . . 211 

a. Catarrh of the Urinary Tubules, or Desquamative Nephritis. 212 
j8. Acute Parenchymatous Nephritis proper . . . .213 

b. Chronic Parenchymatous Nephritis 215 

3. Interstitial Nephritis . . 217 

a. Hyperplastic Interstitial Nephritis — Cirrhosis of the Kidney — 

Genuine Kidney Atrophy . 218 

b. Suppurative Interstitial Nephritis . . . . . .219 

4. Amyloid Kidney 221 

B. Forms of Mixed Albuminuria 224 

1. Pyelitis 224 

a. Acute Pyelitis 225 

b. Chronic Pyelitis 227 

c. Pyelitis Calculosa ... 228 

d. Pyelitis Tuberculosa 231 

2. Hematuria 234 

3. Cysto-Pyelitis and Pyelo-Cystitis 245 

C. Forms of False Albuminuria . . . 246 

1. Cystitis— Bladder-Catarrh 247 

2. New Growths in the Bladder .••'". 254 

3. Bladder-Stone 263 

4. Diseases of the Urethra and Prostate 264 



ANALYSIS OF THE URINE. 



INTKODUCTIOK 

The results of the generally complicated chemical 
processes upon which depends the basis of animal life 
are, on the one hand, the building up of the body, and 
on the other the breaking down of the same, both 
included in the common term " retrograde tissue meta- 
morphosis." The used-up material — i. e., that which 
has lost its value to the animal economy — becomes 
eliminated by the skin and lungs (chiefly in gas form), 
and by the intestines and kidneys (in solid or liquid 
form). 

In order to have a perfect conception at various 
times of the nutrition and state of the body (including 
the normal or pathologically changed material), the 
greatest possible care must be exercised in the investi- 
gation of the excretory ducts themselves, their precise 
function, and the nature of the material eliminated by 
them. 

In order that the physician may obtain an adequate 
idea of the changes which take place in the organs of 



10 INTRODUCTION. 

the body, it is important to observe carefully that most 
important secretion of the same, the urine. 

The urine indicates, at least very nearly, by its 
qualitative and quantitative changes, the variation in 
tissue life. It offers in addition the advantage of easy 
collection, and its analysis, so far as it interests the 
practicing physician, can be made with simple appa- 
ratus. The kidney, inasmuch as it is subjected to dis- 
ease, is not a lifeless filtering machine. Through its 
pathological processes material is added to the urine, 
from the presence of which alone is the physician able 
to make a diagnosis. The urine offers also in general 
an indication as to the condition of the entire body 
(including its constitutional diseases), and in particular 
concerning the secretory and excretory urinary appa- 
ratus. On account of the peculiarities of the numerous 
substances excreted by the kidneys, the urine possesses 
a great interest for the physiologist and chemist, and 
under certain circumstances for the medico-legal expert. 

The endeavor to diagnose disease from observation 
of the urine extends back to the remotest period of 
medical research. The changes of the urine did not 
escape Hippocrates in his close investigation of diseases. 
He taught his scholars, under his personal supervision, 
the setiological and prognostical signification of changes 
in the urine, so far as the then existing state of the 
other sciences permitted. He directed attention to the 
external characteristics of the urine, its abnormal 
amount, color, and clearness, its cloudy or muddy ap- 
pearance, and the visible differences of the sediment; 



INTRODUCTION. 11 

and he referred these indications to diseases of the 
urinary organs. However arbitrary his explanations of 
the appearances may be, his observations are for the 
most part correct. He even endeavored to demonstrate 
the influence of various foods and drinks on the consti- 
tution of the urine. We find also in the descriptions of 
diseases by Grecian writers the character of the urine 
considered according to his methods, without departing 
materially from the views of the great Choic physician. 
Since Galen more sharply defined and systematized the 
teachings of Hippocrates, they have prevailed as incon- 
testable truths. For a long time after Hippocrates the 
investigations on the urine made no progress. Through 
the following century one finds but an occasional writer 
who added anything by his own investigations to these 
transmitted treasures. 

To the Arabian Ibn Sina (980-1037), usually known 
as Avicenna, belongs the merit of having called atten- 
tion to the fact that different external circumstances, as 
fasting, wakefulness, over-exertion, and strong emotions, 
have an influence upon the character of the urine. He 
proved also that absorbed medicines which are excreted 
by the kidneys would cause an accidental coloring of 
the urine. By his successors in the Arabian school 
nothing of importance was added, although, particularly 
in the East, each court had an examiner of urine (uro- 
scqperi). The most important writer on this subject in 
the ancient and middle ages is without doubt Johannes, 
surnamed Actuarius, who lived in the thirteenth centuiy 
at the Byzantine Court. Uniting his experiences with 



12 INTRODUCTION. 

the observations of the Hippocratic-Galenic schools, he 
treated in his seven-volumed work wept ovpcov, in the 
minutest detail, the physiological and pathological 
changes of the urine. He gives even a description of 
the best methods of observation. In this he excels 
because of his clearly detailed demonstration. This 
work, in which nearly everything was exhausted which 
could be accomplished by the then existing methods, 
found in succeeding time so little emulation that this 
part of aetiology more and more declined. How far the 
interpretation of changes in the urine had advanced is 
most clearly demonstrated by the circumstance that it 
furnished material for the satirical representations of the 
Dutch school of genre painting, as well as for many 
comedies of Moliere and other poets. 

As they had most defective ideas as regards the 
chemical composition of urine, it was possible for the 
old observers to take into consideration only its physical 
properties. We can expect true progress only when 
chemistry and its methods of investigation have under- 
gone marked development. This decided advance dates 
from the time of Lorenzo Bellini of Florence (1643- 
1704). Bellini evaporated the urine, and observed that 
by the gradual addition of water the residue was again 
dissolved, and the solution gradually brought back to 
its original condition, through different degrees of color 
and taste. He concluded thereupon that the variation 
of color and taste depended upon the ratio of the con- 
tained water to the solid constituents — a conclusion upon 
which even now Vogel's color scale is based. 



INTRODUCTION. . 13 

Now important chemical discoveries followed quickly 
upon one another. Willis discovered sugar in the urine. 
Brandt discovered phosphorus, the origin of which Mar- 
graff attributed to the contained phosphates. Kouelle 
the younger discovered urea in 1773, and found that in 
the urine of herbivora were contained carbonate of cal- 
cium and a substance, hippuric acid, related to flowers 
of benzole. In the year 1770 Cotugno found pus in 
the urine; in 1798 Cruikshank declared the relation 
of this condition to dropsy ; and in 1827 Bright proved 
the connection between kidney disease and albuminuria. 
At the same time the latter turned his attention to the 
chemical analysis of gravel and calculi. Among the 
numerous deserving works on this subject are those of 
Scheele, Wollaston, Wetzlar, and Prout. 

The present advanced state of uroscopy is due 
chiefly to the labors of two Frenchmen. Eayer's re- 
searches, which are included in his great work "Les 
maladies des reins" (1837-41), laid the foundation of 
our present knowledge of kidney diseases. Becquerel, 
the son of the renowned physicist, had busied himself 
for a long time with urine analysis under Andral's di- 
rection, to whom he modestly assigns the credit of stim- 
ulating him to his investigations. He published the 
results of years of observation in his work " Semiotique 
des urines" (1841). Through the thirty years which 
followed the publication of that book many observers 
turned their attention to this subject, so that no other 
part of organic chemistry possesses so full a literature 
as this. 



14 INTRODUCTION. 

After this short sketch of the development of our 
subject, it only remains to describe in a few words the 
arrangement of the matter which is here offered. After 
a cursory account of the microscopical construction and 
the function of the urinary apparatus, without a knowl- 
edge of which an understanding of its pathology is 
impossible, the physical properties and the chemical con- 
stituents of the urine will be separately treated, at least 
so far as is important for the practicing physician. A 
description of the microscopical part, viz., the sediment, 
will then be added. The many repetitions which occur 
are suitable rather than blameworthy for the beginner. 

It is to be hoped that the short table for the method 
of investigation will not be useless to the beginner. 
The conclusion is formed of a compendium of the simple 
uncomplicated diseases of the urinary apparatus, as far 
as the indications form valuable signs for their diag- 
nosis. 



CHAPTER I. 

HISTOLOGY OF THE URINARY ORGANS. 
1. THE KLDKEYS. 

If one cuts through the kidney from the papilla to 
the fibrous capsule, it is possible to clearly discern with 
the unaided eye a concentric arrangement of layers, i. e., 
the striated medulla and the more granular cortex sur- 
rounding the same. 

If the blood and urinary vessels have previously 
been treated with different-colored injection fluids, it is 
possible to distinguish further subdivisions on the cut 
surface. 

In the papillae and close upon the same the kidney, 
by injection of the urine-tubes, shows striations; this 
portion is known as the papillary part of the medulla. 
Above this comes a section which is also striated, but 
the striations alternate with those filled with the colored 
injection fluid of the blood-vessels ; this is known as the 
boundary or limiting layer of the medulla. The third 
and outermost layer surrounding the others is called the 
cortical layer. 



16 



ANALYSIS 01 THE URINE. 



By the colored injection fluids we distinguish the 
two component parts of the cortex. One of these is 
striated, and contains the injection fluid of the urinifer- 
ous tubes, which striations are the direct continuations 
of the straight tubes of the medulla, and are called 
medullary rays (Markstrahlen), or the prolongations of 




Fig. 1. — Plane section through the kidney of a dog: the urine- and blood-vessels in- 
jected, p, papillary part, and g, boundary or limiting layer of the medulla ; r, cor- 
tex. The dark striations of the medulla, h, are bundles of urine-tubes. The con- 
tinuations of the same into the cortex are the medullary rays, m. The light 
spaces of the medullary portion, b, correspond to the fasciculi of blood-vessels 
in the medulla. "The light spaces of the cortex studded with dots (glomeruli), 
c, represent the situation of the labyrinth. 



the pyramids ; the other part shows principally small 
round bodies (glomeruli), colored by the injection of 
the blood-vessels, and is the so-called labyrinth of the 
kidney, or, in a narrower sense, the cortex. 

In support of this, with the microscope we find the 
papillary part to be made up of straight tubes ; the 
boundary, partly of straight tubes and partly of straight 



HISTOLOGY OF TEE URINARY ORGANS. ' 17 

blood-vessels ; the medullary rays, principally of straight 
urine-tubes ; and finally the labyrinth, partly of looped 
urine-tubules, and partly of tortuous blood-vessels. 

This system of blood-vessels and urine-tubes is sup- 
ported by a meagre stroma, denser in the medulla than 
in the cortex. On the external surface of the kidney 
this substance becomes a delicate membrane, which is 
loosely adherent to the fibrous capsule. The capsule is 
composed of ordinary connective tissue, with numerous 
fine elastic fibres. It envelops the whole organ, is in- 
serted in the hilus, and, surrounding the blood-vessels, 
sends prolongations to the pelvis of the kidney. 

The urinary tubules have their origin in the laby- 
rinth. Each begins there with a spherical dilatation 
(capsula Malpighii), and " continues as a narrow neck, 
opening to a wider tube, which, after many windings, 
runs toward the medulla. When, as a wide, convoluted 
tube, it has reached the boundary, it suddenly becomes 
of less calibre, and as a narrow canal penetrates more 
or less deeply into the medulla; here the descending 
straight tube turns on itself, forming a narrow loop 
(Henle's loop), and runs directly upward toward and 
into the cortex. On reaching the cortex the canal does 
not seek the place of its origin, but avoids it and runs 
alongside the nearest medullary ray. Sooner or later it 
loses its straight direction, and with several convolutions 
passes as a widened tube (tubulus contortus) among the 
curved canals of the labyrinth. From there it turns 
and enters one of the tubes of a medullary ray (Bellini's 
tubes), the convexity of its curve directed toward the 
2 



18 



ANALYSIS OF THE URINE. 



surface of the kidney, thus losing its independent course. 
The latter occurs as follows : Several canals run from 
different directions to the same place and become blended 




Fig. 2. — p, Papilla, g, Boundary, r, Cortex. I, Capsula glomeruli. II, Convo- 
luted portion of tubule passing into III, descending branch of Henle's 
loop, h, Henle's loop. IV, Ascending branch of Henle's loop. V, Con- 
voluted portion of tubule joining VI, tubulus Bellinianus. VII, Another 
tubulus Bellinianus. VIII, Common duct. IX, Ductus papillaris. 

into a straight wide tube '.' (tubulus Bellinianus, Fig. 2) : 
this runs a direct course until it reaches the papillary 
part of the medulla, where it unites with a neighboring 

* The quotations are from C. Ludwig. See Strieker's " Handbook of Histology." 



HISTOLOGY OF TEE URINARY ORGANS. 19 

tube and so continues (Fig. 2, VIII.) until the united 
tubes, as the so-called ductus papillaris, empty into one 
of the calices. 

The wall of the capsula Malpighii is made up of a 
mosaic of cells. The glomerulus is not wholly sur- 
rounded by the fluid contents of the capsule, this being 
prevented by a layer of nucleated cells not easily de- 
fined, which covers the bunch of blood-vessels. " Be- 
ginning at the neck of the capsule, and extending as far 
as the commencement of the ductus papillaris, the canal 
wall consists of a tunica propria, lined on the inner sur- 
face with epithelial cells." The tunica propria is a ho- 
mogeneous, vitreous, and elastic membrane. 

The epithelium which lines the basement membrane 
is a single layer of nucleated cells. The form of the 
nuclei is always the same, round, sharply defined, and 
showing numerous granules. The body of the cell, on 
the contrary, varies much as regards form. 

In the convoluted tubes the epithelium forms a con- 
tinuous, jelly-like, opaque mass, with imbedded nuclei. 
A division of this mass into cells corresponding to the 
number of nuclei seems impossible. "This epithelial 
pulp lies only lightly upon the basement membrane ; so 
that by making cross-sections of the tube the mass can 
be readily drawn out in a cylindrical form. Micro- 
scopically, fat-globules and other dark granules can be 
seen in this pulp, which is cleared up by addition of di- 
lute acid. Often after the clearing up by acids isolated 
nuclei appear. In the small canals which form the 
arms of Henle's loops appears a thin and transparent 



20 ANALYSIS OF TEE URINE. 

lining epithelium, the cells of which by their nuclei are 
brought into clear relief." 

On the other side of Henle's loops, where the di- 
ameter of the tubes becomes greater, the epithelium 
presents the appearance of true cylindrical cells, which 
are laid over one another as shingles, in a direction 
from the medulla to the cortex. In the tubuli contorti 
we find again the same jelly-like arrangement as in the 
curved tubes leaving the capsulas Malpighii. In the 
straight tubes, even to the ductus papillaris, the epithe- 
lium is built up of a single layer of sharply defined cy- 
lindrical cells, with their broad bases toward the canal 
wall and their blunt points toward the lumen. (PL I v 
Fig. A, 1.) 

The Blood-vessels of the Kidneys. — The arteria 
renalis sends the greater part of the blood through the 
cortex. Its branches penetrate without forming meshes 
to the limit of the cortex, and here breaks up suddenly 
into very fine arteries, the arteriole interlobulares and 
arteriole rectse. 

The wrteriolce interlobulares run between every two 
medullary rays. Having reached the layer of convo- 
luted tubules, they give off a small branch to each cap- 
sula Malpighii. This little branch {vas off evens glome- 
ruli} pierces through the ball-like termination of the 
urinary canal (according to others, it only presses in), 
and breaks up here " into a free waving bunch of capil- 
laries (glomeruli), which unite again within the capsule 
to form a common venous stem, the vas eff erens glome- 
ruli." This stem leaves the capsule in the same place 



HISTOLOGY OF THE URINARY ORGANS. ' 21 

that the vas afferens enters. After the vas efferens 
leaves the capsule, "it takes its direction toward its 
own medullary ray, or when this is wanting (as in the 
outermost layer of the cortex), at once toward the con- 
voluted tubes, where it breaks up into a number of ca- 
pillaries, forming a network of anastomosing meshes 
around the tubules." The vasa efferentia communicate 
by means of capillaries with one another throughout 
the cortex, and also with the vessels of the medulla, in 
the same manner. 

The arterioles rectce, which go from the cortex into 
the medulla, have their course in the slit-like spaces 
which lie in the limits of the medulla between the bun- 
dles of urinary tubules, and run to the papillae, in the 
mean time dividing up into several parallel branches. 
When these vessels meet the converging bundles of the 
urinary canals, they break up into capillaries surround- 
ing the urinary tubes, and then are distributed to the 
surfaces of the papillae. This network of capillaries 
communicates with that of the cortex. 

From the above-described capillary nets the venous 
stems arise. In the cortex of the kidney, especially 
in that layer external to the glomeruli, the union of ve- 
nous stems is star-shaped (venae stellatae). The com- 
mon venous stem penetrates that part of the cortex en- 
dowed with glomeruli and medullary rays, lies along- 
side of an arteria interlobularis, and receives numerous 
branches from the cortical network. 

The venules rectce run in the same clefts with the 
arteries, and on the border of the medulla unite with 



22 ANALYSIS OF TEE URINE. 

the veins coming from the cortex to form greater stems. 
The capsule receives its vessels partly from the arterise 
interlobulares, and partly from other arterial stems in 
the neighborhood, viz., the arteria phrenica, lumbalis, 
and supra-renalis. Their capillaries run partly into the 
venae stellatse of the cortex and partly into the veins 
corresponding to the above-mentioned arteries. 

The Nerves of the kidney are supplied by the 
plexus cceliacus of the sympathetic. Their termina- 
tions in the kidney are unknown. They run alongside 
the great blood-vessels in the same manner as the 
lymph-vessels which empty into the glands of the groin. 



2. THE EXCRETORY DUCTS. 

The ureters j pelvis, and calices have an external fibrous 
coat, a layer of unstriped muscular fibre, and an internal 
the tunica albuginea of the kidney, and is composed of 
mucous membrane. The fibrous coat is continued into 
ordinary connective and elastic tissue. The muscular 
coat of the ureters consists of three layers. The inner- 
most is composed of longitudinal fibres, the middle of 
transverse, while the external and weakest is again 
made up of longitudinal fibres. In the pelvis the ar- 
rangement is the same. In the calices the muscular 
layers become thinner, and are finally wanting at the 
borders of the papillae. The mucous membrane is thin, 
tolerably vascular, and without glands and papillae. 
The epithelium is in layers, and is characterized by the 
size and form of its elements. The cells in the deep 



HISTOLOGY OF THE URINARY ORGANS. ' 23 

layer are round and small ; in the middle layer they are 
cylindrical and spherical, and possess prolongations; 
while in the outer layer they are many-angled and flat- 
tened, and vary considerably as regards size. (PI. I., 
A, 2.) 

The Bladder possesses the same arrangement of lay- 
ers. The muscular layer is often considerable, but the 
fibres run so irregularly that a schematic representation 
is impossible. The internal layer is found to be made 
up of a network of circular fibres, which form oblique 
and cross meshes about the neck of the bladder, and 
are in greatest quantity around its mouth, forming the 
sphincter vesicae. Upon these circular fibres lie the 
more external muscular fibres, which run in different 
directions. The trigonum Lieutaudi consists simply of 
a thickening of the layers of connective tissue extend- 
ing from the ureters to the caput gallinaginis. The 
mucous membrane has (except at the trigonum) a dense 
submucous layer, which is tolerably rich in blood-ves- 
sels and nerves, especially at the fundus and neck. In 
the neck and toward the fundus of the bladder are 
found glands formed like bunches of grapes, which 
have a cylindrical epithelium and mucous contents. 

The epithelium of the bladder is of several coats, 
and varies like that of the ureters in its different layers. 
The innermost, which lines the cavity of the bladder, is 
composed of cells which show a more flattened appear- 
ance, but differ greatly in size and shape. The middle 
layer is formed of young cells with conical ends turned 
away from the cavity of the bladder. These prolonged 



24 ANALYSIS OF THE URINE. 

ends often extend into the deep layer. The deep layer 
is composed of irregular oval cells, which, as opposed to 
the middle layer, have their smaller ends in the direc- 
tion of the cavity of the bladder. (PI. I., A, 3.) The 
blood-vessels of the bladder are the arteria vesicalis, su- 
perior and inferior, springing from the arteria hypogas- 
trica. These enter the bladder wall at the fundus, 
piercing the muscular layer in an oblique direction. 
Here they give oif branches, which break up into capil- 
laries in the layer of connective tissue beneath the epi- 
thelium. The nerves are found in greatest abundance 
at the fundus, in the connective tissue of which it is 
possible to recognize the axis cylinders of their fibres. 
Their terminations are unknown. The blood-vessels 
and nerves of the ureters are similar to those of the 
bladder. 

The Male Urethra has a corpus cavernosum with a 
fibrous coat and loose tissue similar to that of the penis, 
only much more delicate. It has a glandular organ, the 
prostata, which supports it. The mucous membrane 
permits to be seen beneath it a layer of connective tis- 
sue, rich in elastic fibres. External to this are trans- 
verse and longitudinal smooth muscular fibres, both in 
the pars prostatica and membranous portion of the 
urethra. 

The epithelium of the male urethra is composed of 
cylindrical cells (PL I., B, 1), but in the forward half of 
the fossa navicularis we find papillae and pavement epi- 
thelium. The epithelium of the ducts of the accessory 
glands, as the prostate, Cowper's, and Littre's, and that 



HISTOLOGY OF TEE URINARY ORGANS, 25 

of the vesicula prostatica, is cylindrical and almost in- 
distinguishable from that of the urethra (PL L, A, 4 
and 5, and B, 3). 

The Female Urethra has no bulb ; the mucous layer 
is very vascular, and is lined with pavement epithelium 
(PL L, B, 2 and 3). Only a small number of Littre's 
glands are found. 



CHAPTEK II. 

THE EXCRETION OF THE URINE. 

The function of the kidneys consists in the secretion 
of the urine ; that of the bladder and urinary ducts, in 
the gradual collection, retention, and discharge of the 
same. A perfectly satisfactory explanation of the secre- 
tion and excretion of the urine in all its details is 
wanting. 

Bowman advances the theory (in which he is sup- 
ported by the anatomical construction of the kidneys) 
that the epithelial cells are the secretory organs, and 
that from the glomeruli only water escapes, which 
extracts the other constituents of the urine from the 
epithelial cells. 

Ludwig bases his theory upon the varying blood- 
pressure in the renal vessels, and the interchange of 
constituents by osmosis through the animal membranes. 
He assumes that the pressure in the glomeruli is greater 
than in the capillary system immediately surrounding, 
and that consequently a profuse exudation of water 
occurs from the Malpighian tufts, which contains dis- 
solved salts (also blood serum, a little albumen, and fat- 



THE EXCRETION OF THE URINE. ■ 27 

globules). Accordingly, one finds in the urinary canals 
thin urine and in the surrounding capillaries thickened 
blood. These two fluids of such different densities, 
separated by a thin membrane, cause a ready osmosis, 
by means of which water from the urinary tubes enters 
the thickened blood; on the other hand, the urinary 
tubes receive from the blood the products of retrograde 
metamorphosis (urea and salts). In this manner the 
watery urine becomes more concentrated and richer in 
urea and salts — a true urine. The absence of albumen 
may be accounted for from the fact that it passes 
through animal membrane with much difficulty and 
only under great pressure. Under a pathologically 
heightened blood-pressure in the glomeruli (as stagna- 
tion of the renal venous system), one always finds albu- 
men in the urine, but never under a physiological 
blood-pressure. Though this theory explains many 
physiological and pathological facts, it does not show 
how an acid urine can be secreted from an alkaline 
blood-serum. Hence the mechanical theory of Ludwig 
attributes to the glomerulus a process of filtration, and 
in the further course of the urinary tubes a process of 
osmosis, the office of the epithelium being wholly left 
out of consideration. 

According to Goll and Max Hermann, the difference 
in pressure between the contents of the blood-vessels 
and the urinary tubules constitutes a chief motive power 
which forces the urinary constituents of the blood into 
the urinary tubules. Consequently if the blood-pressure 
in the renal artery is increased, then there is an increase 



28 ANALYSIS OF THE URINE. 

in the amount of urine secreted; but if the blood- 
pressure in the renal artery is diminished, or the pres- 
sure in the ureter approaches the normal blood-pressure 
in the artery, then is the secretion of urine lessened or 
made to cease entirely, long before the pressure in the 
ureter has reached the amount of pressure in the renal 
artery. 

Ustimowitsch and Grtitzner have elaborated these 
theories to such an extent as to demonstrate, by experi- 
ments on the dog, that the secretion of urine is not 
dependent upon the general blood-pressure, but upon 
the local pressure in the glomeruli of the kidney. If 
the medulla oblongata of a dog be divided and the gen- 
eral blood-pressure be artificially increased by a current 
of electricity, the secretion of urine is prevented entirely, 
for the reason that the small vessels of the kidney be- 
come contracted. If now the nerves of one kidney be 
divided, there ensues a profuse secretion of urine on 
that side, while no urine flows through the ureter of the 
other kidney. This is due to the fact that by section of 
the vaso-motor nerves of the kidneys the smallest 
arteries become expanded and relaxed, by which means 
the blood-pressure in these small vessels is increased 
and the secretion of urine brought about. Ustimo- 
witsch also shows that by a diminution of the general 
blood-pressure an increase in the secretion of urine 
ensues. If one, for example, cuts through the sym- 
pathetic nerve, which contains the vaso-motor branches 
for the kidney, the blood-pressure in the aorta is 
reduced, but at the same time an expansion of the small 



THE EXCRETION OF THE URINE. 29 

renal arteries occurs, causing an increase of the urinary 
secretion. 

Heidenhein and Wittich support the theory of Bow- 
man in regard to the secretory function of the epi- 
thelium ; while they prove, by their experiments with 
indigo, sulphate of soda, urate of soda, and carminate of 
ammonium, that these substances become separated by 
the epithelial cells. 

K. Muller's investigations show that the excretion of 
urine is increased by the application of cold to the sMn, 
as fomentations or dressings ; but by the application of 
heat, as in a warm bath, the excretion is diminished, the 
blood-vessels of the skin being dilated. A diminution 
of the quantity of blood in the skin capillaries increases 
the urinary secretion ; while an increase of the former 
diminishes the latter. 

According to Wendt, the increase of intra-abdominal 
pressure hinders the excretory process, probably by an 
increase of pressure in the renal veins, by which circum- 
stance, as we know (Ludwig), the secretion of mine is 
checked. 

Maly, Donath, and Posch have proved that, by the 
agency of osmosis, an acid fluid may be obtained from a 
watery solution of several salts (as mono- and di-sodic 
phosphates), which together give a neutral or slightly 
alkaline reaction with litmus. This is a discovery of 
importance, as it obviates the necessity of attributing to 
the renal epithelium the chemical property of acid 
formation. 

Notwithstanding all these theories, there is no hypo- 



30 ANALYSIS OF THE URINE. 

thesis which gives a perfectly satisfactory explanation of 
all the physiological and chemical processes of urinary 
secretion. We must therefore look upon the excretion 
of urine as a compound process of secretion and filtra- 
tion. 



CHAPTER III. 

THE URINE. 
A. A GEKEKAL DESCRIPTION. 

The urine is the secretion of the kidneys, and under 
normal conditions is essentially a solution of such ingre- 
dients as belong to retrograde tissue-metamorphosis. It 
is a solution of urea and chloride of sodium, to which 
are added in less proportion other organic and inorganic 
constituents of the blood, as well as certain foreign 
matters introduced into the organism, which are excreted 
through the Mdneys unaltered or having previously 
undergone chemical transformation. 

In a normal condition the urine contains in part 
organic constituents, as urea, uric acid, creatinine, hip- 
puric acid, xanthine, lactic acid, coloring matters, indican, 
grape sugar (Briicke), etc. ; partly inorganic, as chloride 
of sodium, phosphates of sodium, magnesium, and cal- 
cium, sulphates of the alkalies, iron, and ammonium 
salts as constituents of the coloring matters ; and gases 
— carbonic acid, nitrogen, and oxygen. In pathological 
urine, besides the normal constituents, are found also 
albumen, grape sugar, inosite, biliary matters, fat, sul- 



/ 



32 ANALYSIS OF THE TJRINE. 

phuretted hydrogen, coloring matters of the blood, 
uroerythrine (Heller), leucine, and tyrosine, oxalate and 
carbonate of calcium, carbonate of ammonium, cystine, 
pus, blood, epithelium, spermatozoa, fungi, and in- 
fusoria. 

Before we take into consideration the semeiotic sig- 
nificance of the urine, we will describe its peculiarities 
as far as important to our subject, and the most useful 
methods of investigation. 



B. PHYSICAL CHAEACTEEISTICS. 

1. Amount. 

The amount of urine excreted by a healthy person, 
who eats and drinks moderately, varies between 1,400 
and 1,600 c.c, the mean average for the twenty-four 
hours being 1,500 c.c. 

One passes most in the afternoon, less in the morn- 
ing, and the least at night ; for, under ordinary con- 
ditions, in regard to its quantity, the morning urine is 
least influenced by meals and other circumstances, and 
approaches a mean between the excretions of afternoon 
and night. The urine increases in proportion to the 
amount of imbibed fluids (urina potus). Its amount 
is increased also, though much less perceptibly, by cold 
and atmospheric moisture, whereby the perspiration is 
lessened. During rest, or by such circumstances as 
profuse perspiration or profuse diarrhoea, the urine 
diminishes. 



THE URINE. 33 

2. Specific Gravity. 

The specific gravity of normal urine (1,500 c.c.) is 
between 1*015 and 1*021. When the amount of urine 
is lessened, the specific gravity is correspondingly in- 
creased, standing in inverse ratio. Pathologically the 
urine varies between 1*003 and 1*040. Especially im- 
portant are those cases in which we find with a lessened 
volume a lower, and with a greater volume a higher, 
specific gravity. We often find a higher specific gravity 
in mellituria, in the beginning of acute febrile diseases, 
and after the administration of neutral salts. An in- 
creased amount and a specific gravity between 1*030 and 
1*040 is suggestive of mellituria. A lower specific 
gravity is to be observed in hydruria, urina spastica, and 
urina potus. 

The specific gravity is best obtained by means of a 
pyknometer, or by scales ; though for practical purposes 
less complicated means of investigation answer. For 
immediate determination the urinorneter is very con- 
venient. 

The surest method of ascertaining the exact specific 
gravity by the urinorneter is as follows : One fills a 
small standing glass cylinder tube four fifths full of the 
urine; the froth being removed by filter paper, the 
urinorneter is allowed to sink into the urine guided by 
the supported right hand, never being allowed to come 
into contact with the side of the tube. Bring the eye 
on a level with the surface of the urine, and read the 
division corresponding with this surface (not the upper 



34 ANALYSIS OF THE URINE. 

rim of the fluid raised slightly on the stem by attrac- 
tion). Touch the stem, causing the urinometer to sink 
slightly in the fluid ; and, when it comes to rest, read 
again. 

In all urinometrical observations, the urine should 
have a temperature between 12° and 17° C; otherwise 
considerable errors may be made. 

If the amount of urine is small, dilute with even 
three or four volumes of water : test as directed above, 
and multiply the number read off by the number of 
volumes made by the dilution. For example : If three 
volumes of water be added to one volume of urine, and 
we read 1*008, to obtain the real specific gravity of the 
original fluid 1-008 is multiplied by 1 + 3 = 4 (1-008 X 
4 = 1*032). The solid materials (on which the specific 
gravity depends) which formerly were dissolved in one 
volume are after the dilution dissolved in four vol- 
umes : the specific gravity is therefore only one fourth 
of the specific gravity of the original ; or, what is the 
same thing, the specific gravity of the original is four 
times the specific gravity of the dilution. 

3. Solid Ingredients. 

In normal urine the solid materials excreted in 
twenty-four hours are generally 60 to 70 grammes. 
Should we find say 200 grms., diabetes is indicated. If, 
on the contrary, we find a very small amount of solids 
excreted, say 20 grms., and the quantity of urine not 
correspondingly diminished, it indicates hydruria, In 



TEE URINE. 35 

order to estimate the amount of solid constituents ex- 
creted in twenty-four hours, one can employ either the 
coefficient of Trapp (2), or that of Haser (2-33). (For 
the exact determination, see Chapter V.) By multiply- 
ing the decimal of the specific gravity by the coefficient, 
we have the result (in grammes) of the weight of solids 
contained in 1,000 c.c. of urine. Hence, if we have the 
entire amount passed in twenty-four hours, we can 
easily estimate the weight of solids contained in the 
whole. For example, we have 1,500 c.c passed in 
twenty-four hours, of sp. gr. 1*020; to estimate the 
weight of solids in 1,000 c.c, we multiply the decimal 
20 (the last two figures) by the coefficient of Haser, 
2*33 (20X2*33 = 46-60), and the product, 46*60, is the 
weight in grammes of the solids in 1,000 c.c. of the urine. 

Now by the proportion, 1,000:46*60: : 1,500: a?, we 
are able to estimate the amount of solid materials con- 
tained in the excretions of the twenty-four hours. In 
the given example x would represent the unknown sol- 
ids, and # = 69*90, the weight in grammes of the solid 
materials contained in the twenty -four hours' secretion 
of normal urine. 

In the following examples will be considered the 
amount of solids excreted in different urines in the 
course of twenty-four hours : 

Example 1. — Amount of urine, 4,000 c.c.,- sp. gr., 
1*007. 

7X2*33 = 16*31. 

1,000 c.c. of this urine contain 16*31 grms. of solids, 



36 ANALYSIS OF TEE URINE. 

and 4,000 c.c. contain 65*24. We see in this example 
that the quantity of solids is normal, but simply the 
amount of fluid has increased. This may be an indica- 
tion of polyuria, or may be entirely physiological, as 
urina potus. 

Example 2. — Amount of urine, 6,000 c.c. ; sp. gr., 
1-013. 

13X2*33 ==30-29, solids contained in 1,000 c.c. 
and as 1,000 : 30-29 : : 6 ; 000 : x, 

# = 181*74 grms. 

In this example we find the amount of solids excreted 
in twenty-four hours to be more than double the nor- 
mal quantity. This urine would consequently suggest 
diabetes. 

Example 3. — Amount, 2,000 c.c; sp. gr., 1*005. 

5X233 = 11*65. 
1,000 : 11*65 :: 2,000 : x. 

2,000 c.c. contain 23*30 grms. of solid materials. The 
solids are deficient here in the twenty-four hours' excre- 
tion, and hydruria is indicated. 

The differential diagnosis between diabetes insipidus 
and hydruria on the one hand and urina potus on the 
other, as well as between oliguria and normal urine, can 
be made by an estimation of the solid constituents. 

Besides these, other valuable conclusions may be 
drawn from the amount of solids and the specific grav- 
ity; but each case has a special significance. For 
example, if we have a diseased kidney, the amount of 



TEE URINE. 37 

urine normal or diminished, and with a very low spe- 
cific gravity, then we can determine, since urea com- 
poses nearly half the solid constituents, that there has 
not been a sufficient quantity of the same excreted ; 
"consequently we may expect uraemia, and very soon. 

As the proportion of the solid constituents to one 
another does not remain constant, therefore we can not 
estimate accurately any single one from the specific 
gravity. The variation in the amount of solids may 
be 6 per cent, (in urine with abnormal constituents, 
even more). For example, if we found yesterday 
1,000 parts of urine to contain 50 grms. of solids, and 
to-day 47 or 53, we can not speak positively of an in- 
crease or decrease. 

In judging of the variations of the solid matters 
from the specific gravity, we must further take into 
consideration whether the patient has received his cus- 
tomary amount of food, or (as is the case in all febrile 
processes) has fasted. In the latter case we must regard 
30 grms. as the average. If a person having pneumo- 
nia, placed upon a strict diet, excretes 40 grms. of solid 
matters, we must consider it an increase, and that ac- 
complished at the expense of the feverish body. 

4. Consistence. 

The consistence of normal urine is that of a thin, 
easily dropping fluid. Pathologically it becomes viscid, 
as when there is a great amount of pus in a strongly al- 
kaline urine. The urine becomes stringy, similar to the 



38 ANALYSIS OF THE URINE. 

contents of an albuminous cyst. If we dilute with 
water and add a drop of acetic acid, a copious turbidity 
ensues, indicating the presence of an alkaline albumi- 
nate, formed by the action of a strongly alkaline urine 
on the pus. 

Upon the Isle of France, a urine is often observed 
which soon after passage into the vessel coagulates as 
lymph and contains fibrine (nbrinuria). In our lati- 
tudes such urine occurs but seldom, and the condition 
lasts but a moment. We have observed temporary nbri- 
nuria in cases of villous tumor of the bladder. In these 
cases the fluid, of a yellowish-red color and containing a 
slight quantity of blood, thickened after a few moments 
to a quivering, jelly-like mass, which could not be 
poured from the receptacle. 

If we shake normal urine, a foam appears which 
vanishes soon on standing. If the urine contains sugar 
or albumen, the foam remains for a considerable time. 

5. Color, 

The color of a normal urine whose specific gravity 
is 1*020 and amount in twenty-four hours 1,500 c.c. is 
wine-yellow. By concentration, it becomes dark wine- 
yellow, then amber-yellow ; by dilution it passes through 
pale wine-yellow to straw-yellow. Morning urine 
from freely perspiring persons has always a darker, 
and from urina potus a lighter, color. The color 
of the urine, besides the physiological changes, is, 
subjected to greater variations in disease ; in the latter 



THE URINE. 39 

case the appearance is frequently affected by abnormal 
coloring matters. 

The urines may be classified according to their de- 
parture from the normal standard of color. 

1. Almost colorless urine, — Especially in neuroses, 
there is sometimes a " urina spastica " produced, and the 
urine can scarcely be distinguished from water. By 
other causes, such as hydruria, as well as diabetes, the 
urine is rendered almost colorless, though the yellow 
color is still recognizable. By standing a few hours 
a light may become a darker urine. Pale urine 
occurs when, with a normal amount of coloring mat- 
ters, the water is increased (as in urina potus, urina 
spastica), or when with a normal amount of water 
the coloring matters are in less quantity (as in granu- 
lar kidneys) ; but in most cases an increase of water 
and lack of coloring matters concur in making the 
urine pale. 

2. Highly colored urine, — These urines are dark yel- 
low with a tendency to red, even to flame-red. This is 
not simply due to a concentration of the urine, but 
often depends upon the presence of uroerythrine. This 
is brought about by acute febrile processes in a stage of 
increase or climax. 

3. Blood-red or govrnet-red wrvne is always caused by 
foreign coloring matters. A number of vegetable mat- 
ters excreted through the kidneys impart to alkaline 
urine a red color. A similar appearance is caused by 
the passage of blood into the urine (for proof of which 
see chapter on abnormal coloring matters). 



40 ANALYSIS OF THE URINE. 

4. Dark brown to nearly black urine is induced by 
methamoglobine from diseases of the kidney, especially 
hemorrhage ; also by the passage of biliary coloring 
matters into the urine (icteric urine), and by the passage 
of coloring matters as yet comparatively unknown ; for 
example, when colored by long-continued intermittent 
fever. 

Sometimes, after long standing, urine of melanotic 
cancer becomes almost black, because the coloring mat- 
ter of melanotic cancer has been found in the urine 
without the existence of the cancer; and vice versa, 
melanotic cancer being present and the color wanting in 
the urine, we are not able to use this as a means of posi- 
tive diagnosis. After the external use of carbolic acid 
(for example, Lister's dressing), we are apt to find very 
dark urine, though this appearance is not always con- 
stant. In children the urine is often seen to be colored 
after some time, from the surface toward the bottom. 
In leprosy the fact is observed that toward death the 
characteristic dark-red urine becomes dark-brown (uro- 
rubrohaBmatin e) . 

5. Green %irine of a dirty hue comes from jaundice, 
and is caused by presence of biliverdine, having the 
same significance as brown icteric urine. (For a con- 
sideration of biliary coloring matters, see chapter on 
abnormal coloring matters.) 

6. Dirty-blue urine. — This shows generally a dark- 
blue skin and a similar sediment from indigo. This has 
always an alkaline reaction, and exists chiefly in connec- 
tion with cholera and typhus. 



THE URINE. ■ 41 

6. Transparency and Fluorescence. 

Normal urine is always clear and transparent, and 
shows after standing some time a mucus-cloud. Micro- 
scopically we find isolated pavement epithelium and 
young cells. The urine of women shows usually a 
denser mucus-cloud (nubecula) and more epithelium 
(generally overlapping), which comes from the vagina. 
Pathological urine may become clouded from any of 
those substances which after long standing form a 
sediment. 

If we desire to prove by chemical means the origin 
of this cloudiness, we proceed as follows : A test tube 
is a third filled with the urine to be examined, and is 
carefully heated over a Bunsen burner or spirit lamp. 

(a.) If the cloudiness disappears, salts of uric acid 
(urates) are indicated, which were suspended in the 
urine on excretion. 

(&.) If the cloudiness increases, on the other hand, 
calcium carbonate, suspended earthy phosphates, or the 
albuminous cell elements (pus, blood) are indicated. 

To distinguish between the above, we add a few 
drops of acetic acid. If the urine clears up, the earthy 
phosphates composed the cloudy precipitate. If, on the 
contrary, it becomes more cloudy, this in most cases is 
due to suspended pus or blood. 

(<?.) If it remains unchanged, or we notice after the 
addition of acetic acid a slight increase of the cloudi- 
ness, mucus and bacteria are present in unusual quan- 
tity. 



42 ANALYSIS OF THE URINE. 

Normal urine shows at times a peculiar white fluo- 
rescence, the cause of which is not exactly understood. 
Alkaline urine shows by reflected light a greenish, by 
transmitted light a yellowish-red, color. Some urines 
show the spectrum of urobiline. 

7. Odor. 

The odor of fresh normal urine is slightly aromatic. 
The cause of this is at present unknown. If the urine 
has become alkaline by standing, we perceive an ammo- 
niacal odor. From destructive processes in the bladder 
we observe frequently a peculiarly repulsive, foul, and 
even faecal smell. By the use of certain foods and 
medicines, the odor of the urine is strikingly altered. 
For example, asparagus, cauliflower, etc., impart a repul- 
sive smell. Turpentine administered internally induces 
the perfume of violets. The odorous principles of 
cubebs, saffron, and some other substances pass into the 
urine. 

8. Reaction. 

Normal urine possesses an acid reaction, which is 
due especially to the acid alkali-phosphates. The acid 
reaction may be also due to the presence of a free 
organic acid (lactic ?) ; but the part this acid plays is a 
subordinate one. If we add to a fluid containing free 
acid a solution of hyposulphite of sodium, it causes a 
turbidity which occurs instantly or in a few minutes 
(by the separation of sulphur), according to the amount 
of free acid present. If we apply this test to urine, 



THE URINE. ■ 43 

after twenty-four hours there is but a slight precipitate, 
if any. There can consequently be only a small amount 
of free acid in the urine, although this proof is rather 
unsatisfactory. 

Sometimes, directly after a meal, an alkaline urine 
is passed ; but after a few hours this phenomenon disap- 
pears, and it is without clinical significance. 

A strongly acid reaction of the urine is important to 
the physician, inasmuch as it gives rise to the origin of 
certain sediments or concretions which irritate the kid- 
neys and urinary passages (Vogel). 

By standing, an acid urine becomes neutral or 
alkaline. By administration of the alkaline or earthy 
carbonates, or the salts of the vegetable acids (acetic, 
malic, tartaric, etc.), which in the organism become car- 
bonates, an alkaline reaction is imparted to the urine ; 
just as the ammonium carbonate, which is formed from 
urea by the taking up of the elements of water, renders 
the urine alkaline after standing. At first the ammo- 
nium carbonate just sufiices to neutralize the urine ; 
consequently the neutral reaction has the same significa- 
tion as the alkaline. 

A strongly alkaline urine may almost always lead us 
to conclude that an affection of the bladder exists — if 
we exclude the formation of the carbonates by decom- 
position. 

The reaction of the urine is usually tested with deli- 
cate blue and red litmus paper. We must observe 
whether the urine is alkaline when it is excreted from 
the bladder, or has become so after its passage, and in 



44 



ANALYSIS OF THE URINE. 



what length of time it has become alkaline ; and further, 
whether the alkalinity is due to the ammonium car- 
bonates (from the breaking up of urea) or the fixed 
carbonates (taken into the body as nourishment or 
medicines). We may determine to which the alkalinity 
is due ; for in the first case, on exposure for some time 
to warm air, the red color of the litmus paper will 
return ; but, if the reaction is from fixed alkalies, the 
test paper remains blue after drying. 

Sometimes we observe urine which colors blue litmus 
paper slightly red, and the red paper slightly blue. 
This reaction is known as amphoteric. It has no satis- 
factory explanation, and is without ^etiological value. 

C. CHEMICAL COMPOSITION. 

a. Normal Organic Constituents. 

In referring to the constituents of the urine, so 
called, the following table expresses the average quan- 
tity of each excreted in twenty-four hours : 



Constituents. 


Grammes. 


Pee Cent. 


Total solids 


60 —70 
30 —40 
0'4— 0-8 
0-5— 1-0 
0-3— 1-0 
10 —13 
0-9— 1-3 
2-5— 3-5 
1-5— 2-5 


4-3 —4-6 


Urea 


2-5 —3-2 


Uric acid 


0-03 —0-05 


Creatinine ....-- 


0-036—0-062 


Hippuric acid 
Chlorides .... 




0-02 —0-06 




0-7 —0-8 


Earthy phosphates 

Phosphates 

Sulphates 


0-07 —0-08 
0-19 — 0-2'2 
0-16 —0-17 



THE URINE. 45 

We see from this that urea and the chlorides are the 
principal constituents. It is apparent that, if one of 
these matters is wanting or is excreted in diminished 
quantity, it will influence greatly the specific gravity. 
This does not hold true to the same extent with the 
other constituents, which are relatively excreted in very 
small quantity. 

The dissolved gases are of little importance. Car- 
bonic acid gas exists in greatest quantity — 60 to 150 c.c. 
in 1,000 c.c. of urine. Nitrogen is next in amount, 
and there are only traces of oxygen. 

1. Urea. 

Urea, CO N 2 H 4 , is the most constant of all the con- 
stituents of the urine, and exists in greatest quantity, 30 
to 40 grms. being secreted in twenty-four hours by a 
healthy adult. On a flesh diet more is excreted, less 
upon a mixed, and least of all upon a strictly vegetable 
diet. From inanition the secretion may fall to 20 and 
even to 15 grms. In calculating the extent of tissue- 
metamorphosis, if the patient is on a low diet these 
latter figures must be considered the average. 

The simplest way of separating the urea from a 
urine is to throw down the inorganic salts by addition 
of the usual barium mixture, filter, and evaporate the 
filtrate to dryness; extract with common alcohol, filter, 
evaporate the filtrate, and allow the crystals of urea to 
form by adding absolute alcohol and setting aside to 
evaporate spontaneously. Another method is as fol- 



46 ANALYSIS OF THE URINE. 

lows: Evaporate the urine to a thin sirup, and add 
concentrated nitric acid in the cold, whereby the nitrate 
of urea is precipitated. These crystals are now treated 
with carbonate of barium, and the urea is extracted 
from the dried mass by means of alcohol. 

Synthetically urea can be formed from cyanate of am- 
monium. We fuse 80 parts of anhydrous ferrocyanide 
of potassium with 30 parts of carbonate of potassium in 
a crucible, and the resulting potassium cyanide (KCN) 
is converted into potassium cyanate (KCNO) by oxi- 
dation with 150 parts of red oxide of lead at a gentle 
heat. The white melt is then thrown upon an iron 
plate. After cooling, the potassium cyanate (KCNO) 
is dissolved in a solution of 80 parts of ammonium sul- 
phate ((NH 4 ) 2 S0 4 ) to 500 parts of water. Then by 
decomposition we have ammonium cyanate and potas- 
sium sulphate (NH 4 CNO and K 2 S0 4 ), filter, and evapo- 
rate the filtrate to dryness. During the evaporation 
the relation of atoms is changed, so that from the cya- 
nate of ammonium urea is formed. 



* /CN 

°< = 
NH 4 


/NH, 
CO< 

X NH a 


Cyanate of ammonium. 


Urea. 



The mass resulting from the evaporation is then 
extracted with boiling alcohol, 100 grms. at a time, and 
allowed to crystallize. 

Urea crystallizes microscopically in white, glisten- 
ing needles, macroscopically in long, clear, four-sided 



TEE URINE. ' 47 

prisms, the ends of which are terminated by one or 
two oblique planes. These are very soluble in water 
and alcohol, but insoluble in ether. By heating on 
platinum foil, ammonia is generated freely. If we 
add a solution of urea to a stale urine or to a secre- 
tion from bladder catarrh, in contradistinction to its 
synthetical formation, it decomposes (by taking up one 
molecule of water) to 1 mol. carbonic acid, and 2 mols. 
ammonia (CH 4 N 2 + H 2 = C0 2 + 2NH 3 ). This de- 
composition ensues when urea is boiled with mineral 
acids, fused with caustic* alkalies, or heated with caustic 
baryta in a closed tube. With nitrous acid or with 
hypochlorite or hypobromite of sodium, the urea de- 
composes, forming carbonic acid, water, and nitrogen. 

Mercuric nitrate gives with solutions of urea a white 
flocculent precipitate, which, according to the concentra- 
tion and temperature of the fluid, contains three or four 
equivalents of mercury to two of urea. Urea also enters 
into combination with chloride of sodium. 

If we add pure nitric acid to a concentrated 
urine or a concentrated solution of urea, we obtain 
beautiful microscopic and often macroscopic rhombic 
tables. 

If we only have a drop of a fluid containing urea to 
be analyzed, we add a drop of nitric acid on an object- 
glass, and after warming slightly set it aside to crystal- 
lize. With the microscope we see single rhombic or 
hexagonal plates, or we observe them in greater mass 
more or less perfectly formed, arranged in shingle-form 
layers, exhibiting their acute angles (nitrate of urea, 



48 ANALYSIS OF THE URINE. 

PL III, A, 1). The acute angles are 82°. The proof 
by forming nitrate of urea is most frequently used, on 
account of the characteristic shape of the crystals. 

With albuminuria the nitrate of urea crystallizes 
in penicillated needles. (K. B. Hofmann, "Zooche 
mie.") 

Upon the addition of oxalic acid to a concentrated 
solution of urea, crystals are formed which in appearance 
resemble those of urea nitrate (PL III., A, 1) ; the for- 
mer crystals, however, appear more irregular in shape 
than the latter. This reaction is only employed to con 
firm what has been already proven by the nitric acid 
test. 

All tests for urea must be applied to concentrated 
urine. If albumen is present, it must be separated by 
coagulation and filtration, and the filtrate concentrated. 

In order to determine that a given fluid is urine, the 
presence of urea and uric acid must be proved. If 
there are only a few drops of the fluid, the micro- 
scopical test for nitrate of urea is to be employed ; but 
it must not be forgotten that transudates may also con- 
tain urea. 

As urea is present in greater quantity than any other 
constituent of the urine, its percentage may be deter- 
mined, at least approximately, from the specific gravity 
of the fluid, provided a normal amount of sodium 
chloride is present, no sugar, and no great quantity of 
albumen. 

If the urine to be analyzed contains a normal amount 
of chlorides, neither albumen nor sugar, and has a spe- 



THE URINE. 49 

cific gravity of 1*020-1*024, urea can be said to be 
present in normal percentage (2-2*5 per cent.). 

If, under the above conditions, the specific gravity is 
higher or lower, there will be a corresponding increase 
or decrease in the amount of urea present. If the spe- 
cific gravity is 1*014, the urine contains about 1 per 
cent, urea ; if, on the other hand, the specific gravity is 
1*028-1*030, the urine contains 3 per cent. urea. 

If the chlorides exist in small amount or are inappre- 
ciable, as is sometimes the case with urine of acute 
fevers, and the specific gravity is normal, then urea 
exists in greater than usual percentage. For the chlo- 
rides have a second place (albumen and sugar excepted) 
in influencing the specific gravity, and if these are 
wanting and the specific gravity is 1*020, we know it is 
due to an excess of urea ; for, even if all the other con- 
stituents were excreted in double quantity (as uric acid, 
creatinine, phosphates, and sulphates), they would have 
no appreciable influence on the specific gravity. 

If albumen is present in but small quantity (up to 
0*2 per cent.), which fact we can ascertain approximately 
by the nitric acid test, we need not take it into con- 
sideration; for, if the albuminous precipitate is not 
massive nor curdled, but white, cloudy, and translucent, 
it has no especial influence on the specific gravity. But, 
if the urine contains more albumen (1-2 per cent.), it 
must then be separated by coagulation and filtration. 
For this purpose it is best to take a certain quantity, 
say 50 c.c, and heat to boiling with a few drops of acetic 
acid, filter the urine from the coagulated albumen, and 



50 ANALYSIS OF TEE URINE. 

wash with distilled water until we have a volume of 
fluid equal to that at the beginning (50 c.c). We then 
find the specific gravity of this urine freed from albu- 
men. 

Usually albuminous urines have a less specific grav- 
ity than the normal; because, through diseases of the 
urinary organs, the latter are unable to excrete the 
amount of solids (especially urea) that the healthy or- 
gans excrete, and consequently the specific gravity of 
the urine is less. As regards, the specific gravity, ex- 
creted albumen is very seldom present in such quan- 
tity as to make up for the want of urea. 

If sugar exists in great quantity in a urine, the per- 
centage of urea is always diminished : although, in the 
total amount of urine excreted in twenty-four hours in 
diabetes, the absolute quantity of urea is increased. 
The high specific gravity of such urine depends upon 
the sugar. 

Notwithstanding certain claims, up to the present 
time urea has not been formed artificially from proteine 
substances ; but we must regard such substances as its 
only source. 

Urea owes its origin in part to the retrograde meta- 
morphosis of tissue (including the blood), and partly to 
the breaking down of the unassimilated nitrogenous 
principles. Whether it arises through gradual oxida- 
tion, whether its molecule is split off from a more com- 
plex molecule by a process of fermentation, whether it 
is a splitting up of the albumen molecule itself, or 
whether a gradual disintegration of the albumen mole- 



THE URINE. 51 

cules leads to the formation of smaller molecules from 
which urea results by oxidation, is up to this time unde- 
cided. 

It is known that certain combinations of the uric 
acid group (uric acid, allantoine, creatine, sarkine, xan- 
thine, guanine) and the known derivatives of the pro- 
teines (glycocoll, leucine, asparagine), when introduced 
in large amount, cause an increase in the quantity of the 
solids excreted. 

Urea may under certain conditions be present in 
such amount that the simple addition of nitric acid to 
the urine forms a thick pulp of nitrate of urea. This 
may take place — 

(1.) From a predominant animal diet. 

(2.) In acute febrile processes, until the crisis of 
the disease. The urea arises in these cases from 
an increased disintegration of the nitrogenous ele- 
ments. 

(3.) In diabetes insipidus and diabetes mellitus. 

On the contrary, the amount of urea is lessened — 

(1.) By a predominant vegetable diet, and by fast- 
ing. 

(2.) By chronic disease, when the tissue-metamor- 
phosis is checked (cachexies). 

(3.) By parenchymatous nephritis, accompanied by 
uraemia, especially toward the fatal end (7 grms.). 

The percentage of urea is diminished in urina potus, 
urina spastica, and diabetes. But in the whole quan- 
tity of urine passed in twenty-four hours the amount of 
urea is increased, or at least is normal. 



52 ANALYSIS OF TEE URINE. 

2. Uric Acid. 

Uric acid (C 5 N 4 H 4 3 ) is a constant constituent of 
the urine of the carnivora. From a healthy man 
0'4-0*8 grm. is excreted in twenty-four hours. 

It is soluble with difficulty in 15,000 parts of cold 
and in 1,800 parts of hot water, insoluble in alcohol and 
ether. It is from these circumstances that uric acid ex- 
ists in but small quantities in the urine in a free state, 
but generally is found in combination as urates. 

In a warm solution of the normal alkali phosphates, 
uric acid dissolves more readily than in water, because 
it takes up from the phosphates a part of the alkali, 
forming an acid alkali phosphate and an alkali urate. 

Free uric acid as well as the urates (salts of uric 
acid) appear colored in the sediment, and the more in- 
tense their color the more highly is the urine colored. 

In order to obtain uric acid from the urine, we add 
one part of HC1 to 20 parts of urine, and let it stand 
twenty-four hours. It appears on the bottom and sides 
of the beaker as a fine powder, and on the surface of 
the urine as a film. The forms of the uric acid crystals 
are wedge- and whetstone-shaped ; i. e., they are rhom- 
boidal vertical prisms. (PL II., A.) It appears in these 
forms as a natural sediment. If the uric acid, however, 
is separated by means of hydrochloric acid (HC1), then 
the crystals are somewhat changed ; they appear much 
thicker and more deeply colored. 

Generally we find under the microscope either dou- 
ble wedges in cross form, or groups of thin and long 



THE URINE. 53 

wedges or needles parallel to one another, some of 
which resemble a comb with teeth on either side. Oc- 
casionally we find single long whetstone- or needle- 
shaped crystals. (PI. II., B.) If we filter the solution 
containing the nric acid crystals precipitated by HC1, 
and dissolve the crystals in potassium or sodium hy- 
drate (KOH, NaOH), and then precipitate again by 
HC1, the separated crystals are much whiter. Snow- 
white crystals may be obtained by repeating this 
process. (PL II., A.) The crystals of uric acid may 
also be purified by dissolving them in sulphuric acid 
(H 2 S0 4 ) and precipitating by addition of much water. 

In freshly passed urine we should never find a sedi- 
ment of uric acid or urates. If we find this condition 
often, we must suspect stone or gravel. It happens fre- 
quently that with stone or gravel, uric acid may be ex- 
creted in the form of millet and flaxseed concretions, 
which are too large for a microscopic investigation, and 
therefore no sure diagnosis of their constitution can be 
made. In such cases we can very suitably prove the 
presence of uric acid in a chemical way by the murexide 
test. 

Murexide Test — For this test rub up the concretion 
in a small mortar, and throw into a porcelain dish ; add 
a few drops of nitric acid (HN0 3 ) and a little water, 
and warm carefully over a flame until the uric acid has 
dissolved ; then evaporate cautiously almost to dryness. 
Already during the evaporation we notice, if uric acid 
be present, onion-red streaks on the walls of the dish, 
which vanish suddenly as that portion of the dish ap- 



54 ANALYSIS OF THE URINE. 

proaches the flame. If, when the fluid has evaporated 
nearly to dryness, we add a drop of ammonia to the resi- 
due, the whole interior of the dish becomes a beautiful 
purple-red color (murexide acid = purpurate of ammo- 
nia). If we add, on the other hand, a drop of concentrated 
KOH to the residue, we obtain a beautiful violet-blue. 
The murexide reaction depends on the fact that by the 
addition of HN0 3 and heat, first alloxan and then allo- 
xantine is formed, which on adding ammonia becomes 
murexide. 

Instead of the murexide test, we may also dissolve 
the powdered concretions in some caustic potash and 
precipitate with hydrochloric acid (HC1). We can 
easily distinguish the characteristic whetstone crystals 
of uric acid, if it be present, by placing the crystals 
immediately under the microscope. 

If we have but a small quantity of fluid (say 5 c.c.) 
to test for uric acid, we place it in a watch glass with a 
fine linen thread, add a few drops of acetic acid, and let 
it stand twenty-four hours at a temperature of 15° R, 
and observe with the microscope whether uric acid has 
crystallized upon the thread. 

If we add to an alkaline solution of uric acid a weak 
cupric sulphate solution, a white precipitate of a cuprous 
urate falls. If we add a concentrated cupric sulphate 
solution and boil, we obtain a precipitate of cuprous 
oxide free, as a red powder. In the latter case the 
oxide is reduced to suboxide, and the oxygen goes to 
oxidize the uric acid. (In the colorless solution we find, 
besides urea, allantoin and oxalic acid.) 



THE URINE. ■ 55 

Nitrate of silver in the cold is readily reduced by 
an alkaline solution of uric acid. When a drop of the 
silver nitrate on a filter paper is touched with the uric 
acid solution, there results (if there is contained 10 1 0Q 
per cent, uric acid) a black or (if there is contained 
g 1 per cent, uric acid) a brownish-yellow spot. 

Uric acid in presence of an alkali is oxidized by 
ozone to urea, ammonia, oxalic acid, and carbonic acid ; 
without an alkali, to urea, carbonic acid and allantoin. 

Uric acid furnishes under the influence of various 
oxidizing agents, besides the customary urea, a great 
number of interesting decomposition products which 
may be regarded as ureas, in which the hydroxyl is re- 
placed by an acid radical. The uric acid itself appears 
to contain the residues of two urea molecules.* 

Uric acid is dibasic, and forms correspondingly two 
series of salts, neutral and acid. 

The neutral salts are readily soluble in water, the 
acid salts with difficulty. One part of the acid urate of 
sodium is soluble in 124 parts of hot and 1,150 parts of 
cold water. Consequently, if we find salts of uric acid 
in the sediment, we know that they are the acid salts ; 
on the other hand, if we have uric acid salts in solution 
after the urine has stood and is of the same temperature 
as the surrounding air, we know that the greater amount 
consists of neutral salts. This view is supported by the 
fact that when we add to such a urine a few drops of a 
strong acid, viz., HC1 or HN0 8 , the urine at first be- 

* (K. B. Hofmann, " Zoochenrie," " Abbildungen von Alloxan, Ailoxantin, thi- 
onursaurem Amraon, Uramil, Parabansaure.") 



56 ANALYSIS OF THE URINE. 

comes turbid. If now we examine by the microscope, 
we find no characteristic uric acid crystals, but we see 
simply an amorphous punctif orm mass, which consists of 
the acid urate of sodium. If we allow the urine con- 
taining the turbid cloud to stand for some time, the 
cloud gradually disappears, and in its place we find a 
distinct crystalline sediment of free uric acid. This 
reaction can not be more simply explained than that, 
having found neutral uric acid salts in solution, we have 
changed them to acid urates precipitated as a cloud, by 
the addition of an acid ; for the added acid has taken up 
some of the alkali of the soluble neutral urates, and 
transformed it to acid urates. The acid by a longer 
action on these takes up the rest of the alkali, and the 
uric acid crystallizes. 

It must be remembered that when the test for albu- 
men is performed by pouring HN0 3 down the side of a 
wine glass, between the two fluids which do not mix 
there appears a thick white cloud, often mistaken for 
albumen, but consisting of amorphous acid urates, which 
by longer standing pass over into crystalline uric acid. 

The acid urates of sodium and ammonium will be 
described later, in connection with the sediment. The 
causes of the increase or decrease in the amount of uric 
acid in the urine have not as yet been satisfactorily ex- 
plained. 

Uric acid is recognized as the first step in the forma- 
tion of urea, although it is not probable that all the urea 
in the body passes through this stage. By the accept- 
ance of this would be explained the increase of uric acid 



THE URINE. 57 

in all those cases where the oxidation of the nitrogenous 
products is insufficient ; it may be that either too little 
oxygen has been introduced into the organism, or too 
much uric acid has been formed to be oxidized by the 
amount of oxygen present. There are many facts, how- 
ever, not in accordance with this explanation. 

Uric acid, as a derivative of proteine matters, has a 
similar significance to urea, as regards tissue-metamor- 
phosis. We will therefore generally find an increase of 
uric acid where urea is excreted in greater than normal 
quantity. 

We find, in accordance with this, an increase of uric 
acid — 

(1.) From rich animal as well as vegetable diet, and 
too little exercise in the fresh air. 

(2.) In acute febrile processes, which cause much 
breaking down of the nitrogenous elements of the body. 

(3.) In lung and heart diseases, with dyspnoea. 

(4.) In all cases where the diaphragm is impeded in 
its function, i. e., as with large tumors of the abdomen, 
ascites, etc. 

(5.) In leucaemia, either with an increase of uric acid 
in the diseased spleen, or with diminished oxidation 
power of the red corpuscles, the carriers of oxygen — 
impoverished blood. 

(6.) With the so-called uric acid cachexy. 

A decrease of uric acid occurs usually in chronic af- 
fections of the Mdney, diabetes mellitus (sometimes), 
urina spastica, hydruria, and arthritis. 

The amount of uric acid in the urine may be approxi- 



58 ANALYSIS OF THE URINE. 

matively determined in the following way: Normal 
urine, of specific gravity 1*020-1-024, shows in the sedi- 
ment either uric acid or the urates at the normal tem- 
perature. The former may be isolated by the nitric 
acid reaction. 

If we concentrate a normal urine, we observe a small 
amount of free uric acid in the sediment, and by means 
of the nitric acid test a delicate layer of urates is seen. 
If in these cases the specific gravity is high, the urea is 
increased, as is also the uric acid. If we find with the 
normal amount of urine a considerable " brick-dust P 
sediment and also urates in solution, or if we find a con- 
siderable sediment of free uric acid, then the amount of 
uric acid may be considered as large. If the amount of 
urine is less than normal, we can not draw this conclu- 
sion. In this case we may have a sediment from the 
normal amount of urates, if the amount of water is not 
sufficient to hold them in solution at the usual tempera- 
ture. 

In general, whenever the urea is in less quantity, the 
uric acid is also diminished. All that has been said 
refers only to the percentage. If we wish to estimate 
the entire amount excreted, we must take into considera- 
tion the amount for twenty-four hours. It is most ad- 
vantageous to compare with the normal urine. The 
average amounts to 1,500 c.c, and we have to add as 
much water to the concentrated urine as will bring the 
amount to this standard. If in twenty -four hours only 
1,000 c.c. has been passed, we must add 500 c.c. of water, or 
what is the same thing, to every 10 c.c. of urine 5 c.c. of 



THE URINE. ' 59 

water. We pour into one of two narrow test-tubes 
15 c.c. of normal urine, and into the other 10 c.c. of the 
urine to be examined and 5 c.c. of water, and, after add- 
ing 10 drops of HN0 3 to each, set them aside for 
twenty-four hours. From the amount of uric acid pre- 
cipitated, one can easily estimate whether there is more 
or less uric acid precipitated in the urine to be tested 
than in the standard urine. If more than the normal 
amount of urine has been excreted in twenty-four hours, 
there must be a corresponding dilution of the standard 
urine. 

3. Coloring Matters. 

In normal urine there is a chromogenous matter (in- 
dican) and a pigment (urobiline) ; and several other 
well-characterized bodies are found in the urine, as well 
as one or more pigments which have not been satisfac- 
torily isolated. 

a. Urobiline. Urobiline is a brown resinous mass 
which is easily soluble in water, more readily in alcohol, 
ether, and chloroform. The concentrated solutions are 
brown ; by dilution they become yellow and finally rose- 
red. They do not react upon litmus, show in reflected 
light a beautiful green fluorescence, and in the spectrum 
a dark absorption band between Fraunhof er s lines b and 
F. The fluorescence and absorption band become more 
distinct if we add to the solution some ammonia and a drop 
of chloride of calcium. By the addition of hydrochloric 
acid (HC1) the fluorescence vanishes. By acidifying the 
urobiline solution the absorption band recedes toward 



60 ANALYSIS OF TEE URINE. 

F, becomes paler, and shows more indistinct edges. If 
we add ammonia to the acid solution, the brown or red 
color changes to bright yellow with a greenish tinge. 
The alkaline solution shows the absorption band in the 
same place (if anything, nearer to b) as the original 
solution. 

. Dark fever urine is better suited for the separation 
of urobiline than normal urine. The latter involves too 
much work. We render the urine strongly alkaline 
with ammonia, filter after some time, and add chloride 
of zinc solution as long as a precipitate is formed ; wash 
the precipitate upon a filter with cold, then with hot 
water, until nitrate of silver solution causes no turbid- 
ity : boil the mass with alcohol, dry at a gentle heat, 
dissolve the powdered mass in ammonia, and precipitate 
the solution with lead acetate ; wash the precipitate with 
a little water, and take it up in a small amount of alco- 
hol containing some sulphuric acid, and filter again. To 
the filtrate we add an equal volume of chloroform, and 
shake, adding fresh volumes of water to separate the 
sulphuric acid, until a color is perceived. The urobiline 
is obtained as a resinous mass by evaporating the chlo- 
roform. 

Urobiline is, according to Maly, a reduction product 
of bilirubine. Hoppe-Seyler has succeeded in obtain- 
ing a product identical with urobiline (Maly's hydrobili- 
rubine*) from the coloring matter of the blood, by 
treating with hydrochloric acid and tin. By injection 
of substances which cause the breaking up of the blood 

* See " Annalen der Chemie," 163, p. 77, and Hofmann, " Zoochemie," p. 220. 



THE URINE. 61 

corpuscles, the formation of bile-coloring matters is pro- 
moted ; so it is hardly to be doubted that urobiline is a 
secondary or direct reduction product of hsernoglobine, 
and that its increase possesses an interest for the phy- 
sician. Such a condition is found in febrile processes, 
and indicates therefore a greater breaking down of the 
red-blood corpuscles. 

Urine which, on addition of ammonia and a little 
chloride of zinc solution, shows a green fluorescence and 
the characteristic absorption band, should be regarded 
as moderately rich in urobiline. 

Scherer's urohsematine, Heller's urophseine, Thudi- 
chum's urochrome, etc., are bodies for whose existence 
as proximate principles there is no guarantee. Maly 
has shown further that urochrome and urohaBmatine" 
both contain much urobiline. 

/3. Indican. More recently Heller has shown that 
by the mixing of the urine with nitric acid a peach- 
blossom red, violet, or deep-blue color appears. The red 
he ascribed to urorhodine, the blue to uroglaucine ; and 
the base from which both arise, and which he regard- 
ed as a yellow coloring matter, he called uroxanthine. 
Uroglaucine is found in spontaneously putrid urine, in 
the sediment or as film on the surface ; this has been 
recognized as indigo, in that it is identical with plant- 
indigo in all its peculiarities (crystallizing in needle form, 
subliming as a red vapor, and being deprived of color 
by reduction agents, as sulphate of iron). 

Uroxanthine is regarded as identical with indican, a 
derivative from which is white indigo, which is found in 



62 ANALYSIS OF TEE URINE. 

some plants. Later investigation has rendered it proba- 
ble that the indigo-producing substance of the urine 
differs from plant-indican. We will call it urine-indican. 

If we do not desire a large quantity of pure urine- 
indican, we may precipitate fresh urine with neutral and 
basic lead acetate, treat the nitrate with ammonia, sus- 
pend this precipitate in alcohol, and permit a stream of 
hydrogen sulphide to pass through ; filter from the sul- 
phide of lead, and evaporate with a gentle heat, finally, 
over sulphuric acid in vacuo., The urine-indican thus 
obtained is a pale brown, bitter-tasting sirup. By a 
more complicated method we can obtain it in quantity. 
(Hoppe-Seyler, " Chemische Analyse," 4th edition, p. 
191.) 

The urine-indican is not a glycoside, as by splitting 
up (contrary to older writers) it yields no sugar (indi- 
glucine), but is a sulpho-con jugate compound of indol, 
because by addition of HC1 a large amount of H 2 S0 4 is 
liberated (Baumann). In a free state this acid ether is 
unstable, and decomposition as well as the action of 
mineral acids splits it up. In both these cases an oxida- 
tion takes place ; consequently the formation of indigo 
does not consist in a simple breaking up. One product, 
as we have before shown, is indigo ; the second is a red 
body, the sublimate of which condenses as fine red 
needles, and is identical with Heller's urorhodine. On 
the different proportion of both decomposition products 
depends the color, which the addition of HC1 to the 
urine brings about. 

If concentrated sulphuric acid (H 2 S0 4 ) is mixed 



/ THE URINE. 63 

with a double volume of uriue (which should be 
dropped in from some height), the mixture assumes a 
more or less garnet-red color. The color appears to be 
brought about by various decomposition products (per- 
haps the coloring matters) of the urine. When present, 
sugar, albumen, and biliary matters, as well as their 
decomposition products, undoubtedly take part in this 
color formation ; in which case the mixture becomes quite 
opaque and dark brown. (Heller's urophseine test.) 

By the mixture of H 2 S0 4 with the urine, a strong 
heat is evolved, which causes the separation of several 
constituents, as iodine, the odorous oil of cubebs and 
saffron, etc., which are perceived by the smell. In 
parenchymatous inflammation of the bladder a repulsive 
odor is developed. 

There are many methods of proving the easy chemi- 
cal decomposition of urine-indican in the urine. The 
oldest is the uroxanthine test of Heller, already men- 
tioned. 

(1.) The uroxanthine test is as follows : Pour 3 or 4 
c.c. of pure HC1 into a small beaker glass, to which 
while stirring add 10 to 20 drops of urine. In a 
normal proportion there exists only enough urine- 
indican in the urine to color the hydrochloric acid 
mixture a weak yellowish-red. A greater proportion 
colors the HC1 mixture violet or blue. The richer a 
urine is in indican, the more intense will be this color 
reaction. Often one or two drops of urine suffice to 
color 4 c.c. of HC1 a beautiful blue. If in one or two 
minutes no color appears, the urine-indican is not exces- 



64 ANALYSIS OF THE URINE. 

sive, even if in ten or fifteen minutes a dark red-brown 
color appears. 

If we wish to test an icteric urine for indican, we 
must first remove the bile-coloring matters by lead 
acetate, and test the filtrate for urine-indican, though 
some is lost by this method. 

The color of* the uroxanthine test has unfortunately 
little value, as it does not indicate the amount of urine- 
indican, but only its capability of decomposition, which 
seems to vary. How varying this is, is shown by the 
circumstance that the urine-indican contains sometimes 
more indigo-blue and sometimes more indigo-red. It 
must be observed also that albumen, when treated 
with HC1 after standing a long time, or by heating, 
develops a violet color. The dark blue color, despite 
the faults that may be attributed to this method, 
can be regarded as a sure indication of urine-indi- 
can. 

(2.) JaffSs test.— Mix 10 c.c. of strong HC1 with an 
equal volume of urine, add a drop of solution of so- 
called bleaching powder, or some chlorine water, and 
observe the color. 

(3.) Stokvis's test. — Warm 5 c.c. of urine with twice 
the amount of common nitric acid (to 60-70° R.), and 
shake with chloroform, which takes up the indigo. 
The chloroform shows in the spectrum the characteristic 
band of indigo between C and D. 

Here we will simply refer to an interesting method 
of E. Salkowsky (Virchow's "Archiv," Vol. 68, p. 
407). If indol is introduced into the organism, the 



THE URINE. 65 

amount of urine-indican excreted will be increased. 
The same follows if the small intestine be ligated so 
as to destroy its permeability; for now by pancreatic 
digestion (in the latter stages) much indol will be 
formed. This is evidently reabsorbed into the blood 
from the ligated intestine, and is there changed into 
urine-indican, just as is the injected indol. The albu- 
men of food is also a source of indican; for indol is 
one of the ordinary decomposition products of albumen. 
It is probable, on the other hand, that a portion of 
the albumen in the living body is decomposed by fer- 
mentation, just as outside the body it is destroyed in 
very much the same manner. The albumen of the 
connective tissue is another source of indol, and con- 
sequently of indican. It is hence evident that by 
starvation indican does not disappear from the urine, 
because it is formed at the expense of the connective 
tissue. 

We find an increase of urine-indican after the intro- 
duction of indol, after an exclusively flesh diet, in Addi- 
son's disease, in cholera, and in carcinoma of the liver ; 
and it is enormously increased in all those diseases which 
threaten closure of the small intestine (incarceration), 
but not so much by impenetrability of the large intes- 
tine. It is considerably increased with carcinoma of the 
stomach without the intestines being involved ; also with 
peritonitis. With kidney diseases, except granulated 
kidney, the indican is not much increased ; and with 
chlorosis and leucaemia there is no increase. In general 
there is an increase in chronic consumption and in inani- 



66 ANALYSIS OF THE URINE. 

tion. Fevers do not cause so marked an increase of 
indican as of urobiline. 

There is an increase of urine-indican in central and 
peripheral diseases of the nervous system, as well as 
after the administration of certain drugs, as turpentine, 
nux vomica, oil of bitter almonds, etc. This, however, 
is only demonstrated by the uroxanthine reaction, and 
requires confirmation by more accurate methods. 

4. Other Normal Organic Constituents. 

The remaining organic constituents of the urine we 
will only mention in passing, for they are of little 
value in general diagnosis, because of the care required 
for their identification and separation. 

Creatinine, the strongest recognized base of the body, 
is excreted in the same proportion as uric acid : for a 
sound man, 0'6-l'3 grm. in twenty -four hours. The 
amount is influenced less by a vegetable than an animal 
diet. It is increased in pneumonia, intermittent fever, 
and typhus, but diminished by inanition and advanced 
kidney affections. 

Hippuric acid is present in largest amount in the 
urine of herbivora, and in only small quantity in the 
human urine, being for a healthy man 0*5-1 grm. in 
twenty-four hours. The amount is increased by a vege- 
table diet, after the use of certain fruits (greengages, 
whortleberries, etc.), and after the use of benzoic acid, 
etc. ; also in febrile processes and in diabetes. It is 
diminished by a strict flesh diet. If the excreted mass 



THE URINE. 67 

is considerably increased, as after eating greengages, 
and we then evaporate slightly and add HC1, hippuric 
acid will be precipitated in the same manner as uric 
acid. Otherwise we must employ the method of Meiss- 
ner (Neubauer-Vogel, 1. c. 43), for which a litre of urine 
is necessary. 

Xanthine and the phenylsulphate derivatives are 
found in the urine, but in small quantity. For a quan- 
titative determination of the first it is necessary to 
obtain several hundred litres of urine. The existence 
of the substance yielding phenyl derivatives betrays 
itself by the phenyl reaction of the distillate, if we 
previously acidify the urine with a strong mineral acid 
(e. g., H 2 S0 4 ). From the fact that when we add tar- 
taric acid and distill we have no phenyl reaction in 
the distillate, we conclude that the phenyl (carbolic 
acid) does not exist normally in the free state in the 
urine. 

We mention in passing that up to this time, from 
a derivative of uric acid, oxaluric acid has been 
found in but very small quantity (not less than a hun- 
dred litres must be used to test for it). Parabanic 
acid occurs as an oxidation product of uric acid, 
and by taking up water becomes oxaluric acid. 
This boiled with water forms oxalic acid and oxalate of 
urea. 

Oxalic acid is found in the sediment as calcium 
oxalate. 

In regard to the existence of sugar in normal urine, 
the point is as yet undecided. In every case normal 



68 ANALYSIS OF THE URINE. 

urine contains besides the urates a body which in an 
alkaline solution will reduce the copper salts. 

The assertion that lactic acid is present in normal 
urine needs confirmation. In pathological urine we find 
two kinds of lactic acid. One is present in fermenting 
diabetic urine (lactic acid) ; the other is found after 
phosphorus-poisoning, with acute atrophy of the liver, 
with osteomalacia and trichinosis (paralactic acid). 

b. Normal Inorganic Constituents. 
1. Chlorides. 

In human urine the chlorides consist almost entirely 
of the chloride of sodium (NaCI) and a little chlorido 
of calcium. The average excretion for a healthy man 
is 10 to 16 grms. of NaCI in twenty-four hours (6 to 10 
grms. chlorine). Next to urea, NaCI is the principal 
constituent of the urine. Normal urine has an appre- 
ciably salty taste proportionate to the quantity of the 
contained NaCI. If a drop of urine is carefully evapo- 
rated on an object-glass, we find under the microscope, 
besides the colored monoclinic prisms of the double 
compound of urea with chloride of sodium, also NaCl 
in flat octahedra or in the imperfectly shaped crystals of 
the monometric system. 

For the physician it is often important to ascertain 
quickly and easily whether in the urine the chlorides 
are increased or not. An approximative test is the fol- 
lowing (for more exact determinations see Chap. V.) : 

If a chloride of sodium solution is treated with 



THE URINE. 69 

nitrate of silver, a white precipitate of chloride of silver 
wiU fall: 

NaCl + AgN0 3 - NaN0 3 + AgCl. 



If we have a solution in which both the chlorides and 
phosphates are present (viz., urine), we must first acidify 
with a few drops of nitric acid (HN0 3 ), so that the 
phosphate of silver will not be precipitated at the same 
time, and thereby be mistaken for the precipitate of 
chloride of silver. A slight error from the precipitation 
of uric acid can not be avoided, but it does not essen- 
tially affect this approximative examination. 

The HN0 3 added will not prevent the precipitate of 
the chloride of silver (AgCl), but it will prevent the 
phosphate of silver from coming down. If we use for 
this reaction a solution of nitrate of silver of definite 
strength (AgN0 3 ), 1 : 8, we will find that, by adding a 
few drops of this to normal urine (which contains J-l 
per cent. NaCl), curdy masses of AgCl will fall to the 
bottom. These masses do not separate on shaking the 
glass, and give no milky cloudiness. If the solution 
contains but a small quantity of NaCl, ^ per cent, or 
less, the solution after addition of AgN0 3 shows no 
white curdy precipitate, but a simple cloud, and the 
entire fluid shows a homogeneous milky turbidity. 

To apply this test, we take a wine-glass half full of 
urine, acidify with HN0 3 to prevent the phosphates 
coming down, and then add one or two drops of the 
standard AgN0 3 solution. If the reagent causes a curdy 
precipitate readily falling to the bottom, the chlorides 



70 ANALYSIS OF THE URINE. 

are in no way diminished in quantity. If only a milky 
turbidity arises, and no curdy masses, then the chlorides 
are in very small proportion. If there is no milky cloud 
or turbidity, the chlorides are entirely wanting. We 
can not ascertain an increase of chlorides by this 
method. 

This reaction can be seen in a urine that has been 
tested for albumen with HN0 3 , using this mixture for 
the chloride test. The nitric acid must, however, be 
thoroughly mixed with the urine by means of a glass 
rod before adding the silver salt. But, if albumen has 
been found in such amount as to interfere with the cloud 
or precipitate of the chlorides, it must first be filtered 
off before testing with AgN0 3 , and the test can be 
applied to the filtrate. 

We find a smaller 'proportion of chlorides in the 
wrine — 

(1.) In repose of the body (in the night-time 
least). 

(2.) With all acute febrile processes, especially when 
accompanied by serous exudation or watery diarrhoea. 
The mass of chlorides is directly proportional to the 
amount of urine, but inversely proportional to the 
specific gravity and the quantity of urea, until the crisis 
of the disease. In general only the excess of chlorides is 
eliminated by the kidneys. In inflammatory processes 
the chlorides appear in the exudates (for instance, in 
pleuritic effusions). In general the rule applies, that 
with a steady decrease of chlorides in the urine there is 
a heightening of the disease, and on the other hand a 



THE URINE. • 71 

continued increase of chlorides signifies a better con- 
dition. 

In pneumonia the cnlorides may be entirely wanting, 
but we can not attribute this condition to lessened nu- 
trition alone. In typhus and meningitis they are dimin- 
ished, but do not disappear. The absence of chlorides 
always signifies a desperate condition. 

(3.) In chronic affections accompanied by impaired 
digestion, and in dropsy. 

In urina potus the percentage of chlorides is dimin- 
ished ; but, if we take the twenty-four hours' amount 
into consideration, the diminution is inappreciable. 

An increase of chlorides is observed — 

(1.) With a liberal salt diet. 

(2.) With energetic bodily or mental exercise. 

(3.) In the paroxysms of intermittent fever, some- 
times a little before or after the same. The day after 
we find the average daily amount sometimes a little 
less. 

(4.) With diabetes insipidus. 

(5.) With dropsy, as soon as diuresis comes on, for 
now the chlorides stored up in the body become sud- 
denly excreted. 

2. Phosphates. 

The amount of excreted phosphoric acid (not phos- 
phates) is between 2*3 and 3*8 grms. (average 2*8). In 
robust men the average is 3*5 grms. The daily varia- 
tion may be very considerable. The amount excreted 
increases after breakfast until evening (maximum), and 



72 ANALYSIS OF THE URINE. 

falls during the night till the next morning (mini- 
mum). 

We find an increase of phosphoric acid in the 
urine — 

(1.) After the introduction of phosphorus, phospho- 
ric acid, or soluble phosphates into the organism. 

(2.) After a principally animal diet, and especially 
after the administration of such substances as contain 
more or less free phosphoric acid, as the brain. 

(3.) With all acute febrile diseases (not constant). 

We find a decrease of phosphoric acid — 

(1.) In all urines of a low specific gravity, in urina 
potus, in urina spastica, etc. 

(2.) In kidney and heart diseases, with a less 
amount of urine. 

(3.) With severe disorders of the digestion, and 
with chronic diseases of the brain (except epilepsy). 

Orthophosphoric or ordinary phosphoric acid (H 8 
P0 4 ) is a tribasic acid ; that is, the three atoms of hy- 
drogen may be replaced by a metal. 

In the urine phosphoric acid is combined partly 
with the alkaline earths (earthy phosphates) and partly 
with the alkalies (alkali-phosphates). 

a. The earthy phosphates — viz., calcium and magne- 
sium phosphates — exist in normal urine only in small 
quantities. The twenty-four hours' average for a 
healthy, robust man amounts to 0*9-1*3 grm. The pro- 
portion of the calcium to the magnesium phosphate is 
as 33:67; that is, the amount of magnesium is double 
that of the calcium phosphate. In acid urine these 



THE URINE. 



73 



salts are in solution, but in alkaline urine they are pre- 
cipitated, and are found in the sediment. 

Phosphoric acid forms with calcium three salts, viz. : 



The normal 
or tricalcic, 



The clicalcic 
phosphate, 



The monocal- 
cic or su- 
perphos- 
phate, 



f 



0\ c , 



g>Ca = Ca,(P0 4 ), 



PO-^ o 




>Ca 



I OH 
P0 \ g) Ca+2H 2 = CaHP0 4 +2H 2 

(OH 
PO-^ OH 

°> Ca+H 2 0=(P0 4 H 2 ) 2 Ca+H 2 

Po] OH 
OH 



In the urine we find these last combinations dis- 
solved — no trimagnesic phosphate is known. In the 
urine the first two phosphates are held in solution by 
free acid (?). 

The precipitation of the earthy phosphates is brought 
about by the addition of the alkalies (potassium, so- 
dium, and ammonium). 

The reactions of the salts are as follows : If alkalies 
be added to calcium phosphate, it will be deprived of 
some of its acid : 

3[(P0 4 H 2 ) 2 Ca] + 12KOH = 

(P0 4 ) 2 Ca 8 + 4K S P0 4 + 12H 2 



74 ANALYSIS OF THE URINE. 

If acid magnesium phosphate is acted upon by ammo- 
nia, an ammonium-magnesium phosphate is formed : 

MgHP0 4 + NH 3 + 6H 2 = Mg(NH 4 )P0 4 + 6H 2 

Ammonium-magnesium phosphate formed in this 
way appears under the microscope as fern-leaved or 
snow-flake crystals; after long standing in the glass, 
these crystals become cofim-lid-shaped. (PL III., B.) 

To test for the earthy phosphates, we fill a test-tube 
one third full — if it was not clear with previously filtered 
urine — add a few drops of KOH or (NH 4 )OH, and 
warm until the earthy phosphates separate out as a floc- 
culent precipitate. After setting aside for ten to fifteen 
minutes to settle, we can approximatively estimate the 
amount. If we employ for the reaction an ordinary- 
sized test-tube, 16 centimetres long and 2 c. wide, a 
layer of earthy phosphates 1 c. high corresponds to the 
normal amount in the urine ; if the layer is 2-3 c. high, 
then are the earthy phosphates increased ; if, on the con- 
trary, only single flakes appear, then the earthy phos- 
phates have diminished. 

Beneke gives a more accurate method of determina- 
tion (Neubauer-Vogel, "Analyse des Harries," Chap, 
vii., p. 91, 1). 

If the urine contains no abnormal coloring matters, 
the earthy phosphates are white ; if abnormal coloring 
matters are present, they are variously colored. If the 
urine contains blood-coloring matters, then the precipi- 
tate appears blood-red or dichroic ; with the plant-color- 
ing matters of rheum, senna, etc., rose-red to blood-red ; 



THE URINE. 75 

with bile-coloring matters, yellow-brown; with uroery- 
thrine, gray. 

An increase of earthy phosphates in the nrine is found 
with disease of the bones, especially when diffuse (os- 
teomalacia, rachitis, etc.), with diffuse periostitis, and 
with chrono- or arthro-rheumatic processes ; further, 
after use of mineral waters rich in carbonates, after 
various medicaments, and with exclusive flesh diets (in 
the latter case not constant). 

A decrease of earthy phosphates is observed in Md- 
ney affections. In alkaline urine we naturally find the 
earthy phosphate in the sediment. 

/3. The alkali phosphates are represented chiefly by 
the acid phosphates of sodium and (traces of) potassium. 
The tribasic phosphoric acid forms three salts with the 
alkalies, in which one, two, or three atoms of hydrogen 
are replaced by the alkali metals — 

P0 4 H 2 lS T a P0 4 HNa 2 POJS T a 3 

Monophosphate of sodium. Acid phosphate of sodium. Neutral sodium phosphates. 

Of these three, only the first has an acid reaction, and 
its presence in the urine causes more than any other 
constituent the acid reaction of the same. Both the 
others have an alkaline reaction. All three are (in con- 
tradistinction to the earthy phosphates) easily soluble in 
water and alkaline fluids. 

Of the total phosphoric acid in the urine, two thirds 
is in combination with the alkalies. 

We test for the alkali phosphates (chiefly for the 
phosphoric acid) in the urine with the magnesium mix- 



76 ANALYSIS OF THE URINE. 

ture. (See Chapter IV., No. 10.) If we test for the 
entire amount of phosphoric acid — that is to say, not 
only that in combination with the alkalies, but also with 
the alkaline earths — we take a beaker of 20 c.c. capacity, 
and to 10 c.c. of urine we add a third part (usually 
3 c.c.) of the magnesium mixture. There is formed a 
precipitate of crystalline ammonium-magnesium phos- 
phate (fir-twig or snow-flake), with which comes down 
an amorphous mass of calcium phosphate. If there 
ensues through the entire fluid a milky turbidity, 
the alkali phosphates are in normal amount ; if we 
have a copious precipitate which gives the fluid the 
appearance of cream, then there is a great increase ; 
if the fluid remains transparent, or only a slight tur- 
bidity ensues, we have a decrease of the alkali phos- 
phates. 

This reaction is more for the whole amount of 
phosphoric acid in the urine than for the alkali 
phosphates. As the earthy phosphates only seldom 
occur in large amount in the urine, it is usually not 
considered necessary to separate them by filtration 
before testing for the alkali phosphates. If we have 
previously tested with KOH or (NH 4 ) OH, for the 
earthy phosphates, with a little practice we can easily 
distinguish the others from the turbidity caused by the 
precipitation of the earthy phosphate. If the earthy 
phosphates are present in great amount, we must pre- 
cipitate them with ammonia, filter, and test the filtrate 
with the magnesium mixture. 



THE URINE. 77 

3. Sulphates. 

The sulphates contained in the urine are the neutral 
sulphates of potassium and sodium. 

As the sodium salts predominate in the animal 
organism, so is there in the urine more sulphate of 
sodium (Na 2 S0 4 ) than sulphate of potassium (K 2 S0 4 ). 
The sulphuric acid which a sound man excretes in 
twenty-four hours amounts to 1*5 to 2*5 grms., usually 
2 grms. 

The test for sulphuric acid or the sulphates is made 
quite similarly to that for the phosphates. 

Take 10 c.c. of urine in a beaker and acidify with 
a few drops of HC1 (so that the barium phosphate will 
not precipitate at the same time), and add a third part 
(3-4 c.c.) of the chloride of barium solution. We have 
the reaction — 



[Ba| Cl 2 + Na 2 [SOj = 2 NaCl + BaS0 4 

If we had not previously added HC1, then the sodium 
phosphate in the urine, by the addition of BaCl 2 , would 
be precipitated as barium phosphate. 

If we have previously added an excess of HC1 to 
the BaCl 2 solution, it is not necessary to acidify the 
urine before testing. (Chapter IV., No. 7.) The white 
precipitate which is formed by the BaCl 2 solution is the 
sulphate of barium. 

If an opaque milky cloudiness results from this 
reaction, the sulphates are present in normal quantity. 



78 ANALYSIS OF TEE URINE. 

If the cloudiness is more intense, so .that the urine has 
the appearance of cream, the sulphates are increased. 
If, on the contrary, a translucent light cloudiness ensues, 
then the sulphates are diminished. 

A very pretty approximate test has been given by 
J. Vogel. The normal urine should contain in twenty- 
four hours about 2 grms. of H 2 S0 4 . If a patient passes 
2,000 c.c. in twenty-four hours, this should contain 2 
grms., or in 100 c.c. of urine 0*1 grm. H 2 S0 4 . Take 
now 100 c.c. of this urine and add as much BaCl 2 solu- 
tion as is necessary for the precipitation of half the 
sulphuric acid (0*05 grm.) and filter. If the filtrate 
remains clear after the addition of BaCl 2 , there is no 
more H 2 S0 4 present ; the amount of the latter is there- 
fore very much diminished. If a cloudiness ensues 
after adding BaCl 2 to' the filtrate, add as much BaCl 2 
as will precipitate 0*05 grm. of the acid and filter 
again. If the filtrate remains clear after a fresh addi- 
tion of BaCl 2 , then the amount is normal, for we have 
taken as much BaCl 2 as would be necessary to precipi- 
tate 0*05 + 0*05 = 0*1 grm. (the normal amount) of sul- 
phuric acid. If, however, a turbidity ensues, there is 
more than the normal amount of H 2 S0 4 present. 

An increase of the sulphates or sulphuric acid is ob- 
served — 

(1.) After an exhibition of sulphuric acid or the 
soluble salts of the same, and from sulphur-containing 
compounds or sulphur in the organism. 

(2.) From exclusive flesh diet, for the sulphur of the 
albuminous compounds is oxidized to H 2 S0 4 . 



THE UEINE. 79 

(3.) In acute febrile processes with rich excretion of 
urea. The increase of H 2 S0 4 in this case is referred to 
the increased decomposition of the sulphur-containing 
principles of the body (albuminates). The greatest 
increase is observed in meningitis, encephalitis, and 
rheumatism, as well as affections of the muscular system. 

A decrease of the sulphates occurs with an exclusive 
vegetable diet, as well as at the beginning of typhus, 
and besides (in percentage) in all those urines which 
show a low specific gravity. 

Of the inorganic substances, there are present in 
the urine ammonia (average 0*8 grm.) and traces of 
iron and silicic acid. According to Duchek, the former 
is increased by advance of febrile processes, and dimin- 
ished by convalescence. 

c. Abnormal Constituents. 
1. Albumen. 

In normal urine albumen should never exist; but 
in pathological urine, especially when accompanied 
with diseases of the kidney, albumen is often present 
in considerable quantity. 

After an abundant use of egg-albumen, according to 
CI. Bernard, Becquerel, and others, the same has been 
found in normal urine. Serum-albumen in very small 
quantity (to 0*1 per cent.) may appear even for a year 
in the urine of otherwise healthy men without occasion- 
ing any annoyance. We have observed many such 
cases (" Wiener med. Presse," 1870), as has Vogel. If 



80 ANALYSIS OF TEE URINE. 

this albumen had not been accidentally discovered in 
the urine, the affected persons would never have dis- 
covered it from their general condition. The cause of 
this albuminuria is still somewhat obscure. The urine 
in these cases was strongly concentrated, intensely acid, 
and contained a greater percentage of urea and uric 
acid. In the sediment sometimes nothing, but often 
crystals of oxalate of calcium and uric acid, could be 
discovered. It is probable that this albuminuria, which 
is for the most part periodical and with a very variable 
amount of albumen, is to be explained by the changed 
chemical characteristics of the urine. It is possible, 
besides, that an abnormal innervation of the kidney 
may give rise to this albuminuria. These cases occur 
so rarely, however, that the appearance of albumen in 
the urine may be regarded as no normal indication. 

Why we find no albumen in normal urine may 
best be explained by Ludwig's mechanical theory of 
the urine secretion. This is based, on the one hand, 
upon the relation of the pressure in the blood-vessels 
to that in the urinary tubules, and on the other, upon 
the osmosis of substances through animal membrane. 

Graham divides all bodies into crystalloids and col- 
loids, calling those bodies crystalloids which penetrate 
animal membranes without difficulty, and easily crystal- 
lize, and those colloids which penetrate with great diffi- 
culty or not at all, and do not crystallize. If we apply 
this classification to albumen, and especially to serum- 
albumen, we find that it is a colloid body, for it neither 
crystallizes nor penetrates animal membrane except 



TEE URINE. 81 

under great pressure. As the crystalloid substances 
easily penetrate animal membranes and the colloids do 
not, it is to be supposed that the cause lies in the mole- 
cular constitution ; that perhaps the molecule of albumen 
is greater than that of any soluble salt. This theory 
gains probability if we observe the constant foam on 
an albuminous solution, as also the complex chemical 
composition of the same. We find the extraordinary 
size of the albumen molecule in the expression of its 
atomicity, C 216 H 169 N 2T S 3 68 . 

According to Lud wig's theory, the secretion in the 
glomeruli is a transudation process, and in the urinary 
tubules a diffusion process. We find that in the kidney 
the blood is always separated from the urine by an ani- 
mal membrane. These animal partitions permit the 
crystalloids of the blood (as salts, urea, etc.) easily to 
penetrate ; but the colloids (albumen), under a normal 
blood-pressure, can not pass through, and on this ac- 
count we find no albumen in normal urine. 

If we find albumen in the urine, then the blood-pres- 
sure in the renal vessels is generally increased (hin- 
dered venous circulation, heart disease, amyloid degene- 
ration of the vessels, etc.), or the animal membrane is 
defective in some place (parenchymatous nephritis and 
Bright's disease). 

Of albumen, we chiefly find in the urine serum-albu- 
men and paraglobuline. If to the urine are added other 
albuminous animal fluids (e. g., blood, pus, exudations, 
etc.), we find the variety of albumen corresponding to 

these fluids. Fibrine comes with intense hsemorrhasre 
6 



82 ANALYSIS OF THE URINE. 

and with croupous affections of the urinary appara- 
tus. 

A true fibrinuria — that is, a coagulable urine — 
which occurs on the Isle of France, is seldom observed 
with us. We mentioned this in three cases of villous 
tumors of the bladder (p. 38). We often observe a 
honey-like, sirupy urine, the thick consistence of which 
is not due to fibrine, but to pus dissolved in the alkalies. 
Such urine becomes thinner on addition of water ; and 
if we treat the same with acetic acid, there falls a white 
precipitate of alkali albuminate. This albuminate arises 
from the reaction of carbonate of ammonia on the se- 
rum-albumen of the pus. 

For albumen there are many characteristic reactions, 
but for the urine there are two most satisfactory ones, 
the concentrated HN0 8 and the heat tests. 

1. For the HN0 3 test 10 c.c. of urine should be 
taken in a wine-glass, and then pure colorless concen- 
trated HN0 3 (not fuming) should be allowed to flow 
down the side of the glass, forming a layer beneath the 
urine. Now ? if albumen is present, a white zone will 
appear between the two fluids. This can only be con- 
founded with the urates which are precipitated in a 
somewhat similar manner when present in great amount, 
also with the resin of copaiva. In the case of the 
urates they are not precipitated in the zone between the 
fluids, but somewhat higher up, and are not sharply de- 
fined as a zone, but curl upward from the centre, having 
the appearance of ascending smoke. 

If albumen and much urates are present in a urine 



THE URINE. 83 

at the same time, we obtain by the nitric acid reaction 
two layers, one above the other. The lower layer, 
sharply defined above and below, between the colorless 
acid and the urine, is the albumen. The upper layer, 
gradually becoming more intense and not sharply de- 
fined above, but ascending as a white cloud, consists of 
the urates. A layer of clear urine separates these two. 
The layer produced by the resin of copaiva disappears 
on the addition of a few drops of alcohol. 

If we apply the nitric acid test to normal urine, we 
observe between the acid and the urine a brown ring of 

o 

urine-coloring matters, which in a few minutes becomes 
more voluminous. In febrile processes, when the urine 
contains much coloring matter, this ring is very intensely 
colored. As albumen when present appears in the same 
zone, this does not form now as a white , layer, but is 
more or less tinged with brown. If much indican is 
present, the urine often appears a beautiful rose-red or 
even violet; from the presence of blood-coloring mat- 
ters, brown-red; from undecomposed bile-coloring mat- 
ters, a beautiful green. If a urine is strongly concen- 
trated and we add HN0 3 , a copious crystalline precipi- 
tate of nitrate of urea falls, which under the micro- 
scope shows the characteristic colored rhombic tables. 
From a urine rich in uric acid we often see beautiful 
shining light yellow-colored whetstone crystals, which 
can be easily distinguished micro-chemically from nitrate 
of urea, because they are not soluble in water. 

If the urine contains much carbonic acid, either be- 
cause it is alkaline and contains much ammonium car- 



84 ANALYSIS OF THE URINE, 

bonate, or because it has a neutral or even acid reaction 
and contains much sodium carbonate or free carbonic 
acid (as is the case from use of alkaline and carbonated 
mineral waters), we observe that the fluid by addition 
of HN0 3 becomes sparkling and sometimes even effer- 
vescent. 

If there is doubt about the presence of albumen, 
then we must employ the heat test. It is always well 
to do both. 

2. The boiling test. — If the urine is acid, we take 
8-10 c.c. and boil in a test tube ; it is safer, however, 
to add previously one or two drops of acetic acid. A 
flocculent cloudiness after boiling indicates albumen. If 
the urine is but feebly acid, is neutral, or has an alkaline 
reaction, it is possible that a precipitate may form upon 
heating, which is again dissolved by the addition of 
acetic acid. This precipitate is not albumen, but con- 
sists of calcium carbonate mixed with earthy phosphates 
which were held in solution by carbonic acid ; the car- 
bonic acid being driven off by the heating allows them 
to precipitate (Heller's bone dust). What may happen 
with acid urine is much more liable to occur with neutral 
or alkaline ; it is therefore best to acidify, to avoid con- 
fusion. 

In making the boiling test with alkaline urine, the 
unpracticed may be easily misled as to the presence of 
albumen. The HN0 3 test succeeds here with difficulty 
or not at all, because of the brisk effervescence occasioned 
by the separation of the carbonic acid gas from the am- 
monium carbonate. If the urine is not acidified and 



THE URINE. 85 

contains a small quantity of albumen, the alkali is suf- 
ficient to change tlie albumen to an alkaline albuminate, 
which is not coagulated by heat. If acetic acid is not 
carefully added, but on the contrary an excess has been 
used, an acid albuminate may form, which is also not 
coagulated by heat. A small amount of albumen is 
with difficulty recognized if the urine is turbid and 
remains so after filtration. Alkaline urines are always 
more or less cloudy, and contain for the most part no 
earthy phosphates in solution. Such urine must be 
cleared up before testing for albumen. For this pur- 
pose it must be boiled with a quarter of its volume of 
KOH solution and filtered. (Chapter IV., No. 5.) 
Should the filtrate not be quite clear, we must add one 
or two drops of the magnesium mixture, warm again, and 
filter. This filtrate always appears clear and transparent. 
If we carefully acidify now with acetic acid, we observe 
a slight cloudiness from albumen, though this will 
show more distinctly if to the fluid, after acidifying with 
acetic acid, we add a few drops of a solution of potassium 
ferrocyanide without warming, shake, and permit the 
sediment to settle for a few minutes. We observe now 
on the bottom of the test-tube the white flakes of pre- 
cipitated albumen. 

It is well to know a few other tests. 

a. Acidify strongly with acetic acid, and add to the 
urine its volume of a cold saturated sodium-sulphate 
solution and boil. 

b. Drop into a perfectly clear urine a cold saturated 
picric acid solution. If a white cloud forms, then is 



86 ANALYSIS OF TEE URINE. 

albumen present. (Galippe's test.) The cloudiness 
only lasts for a moment. 

Albumen is found in the urine — 

(1.) When the blood-pressure in the glomeruli be- 
comes greater than normal. This occurs in all disturb- 
ances of the circulation, as heart-disease, impeded venous 
circulation, amyloid and atheromatous degeneration of 
the blood-vessels, etc. 

(2.) In all those diseases which involve an alteration 
of the diffusion membranes of the kidney ; i. e., the 
walls of the tubules with their epithelium, and the 
neighboring fine arteries or their capillaries (parenchy- 
matous nephritis, Bright's disease, etc.). 

(3.) If blood, pus, or any other albuminous fluid is 
mixed with the urine (false albuminuria). 

(4.) Sometimes with hydremia (imperfect nutrition 
of the capillary walls). 

It is also said (Vogel) that albuminuria may result 
from a peculiar albumen that is formed in the blood, 
which penetrates the intact membranes by quite another 
diffusion process. But such a form of albuminuria we 
have never had an opportunity of observing. 

In true albuminuria it is important to observe the 
amount of urine passed in twenty-four hours, for only 
by an increase or decrease of the contained albumen can 
a better, or worse condition of the kidney disease be 
recognized. The most accurate quantitative determina- 
tion of albumen is made by means of the balance, or by 
the employment of a polarization apparatus (Chapter 
V.). These methods are too troublesome for the prao 



THE URINE. 87 

ticing physician, but there remains a method by which 
it may be readily discovered whether albumen exists in 
small (under -J- per cent.) or in great (1-2 per cent.) 
quantity. With a little experience one can estimate 
approximatively the percentage from the appearance of 
the white albumen zone which forms between the fluids 
on the addition of the strong nitric acid. If this zone 
is faint and feebly white, and has no lumpy appearance, 
but is almost transparent and only visible as a sharply- 
defined band on a black background, having the height 
of but 2-3 mm., we may say that, albumen is only 
present in small amount (less than \ per cent., usually 
jL per cent.). If this' zone appears from 4 to 6 mm. 
high, snow-white, opaque, and distinctly recognizable 
without a black background, and of a flocculent appear- 
ance, then albumen is present in considerable quantity 
(i~k P er cen ^-)* But ^ on the addition of the acid the 
albumen appears lumpy and flaky, and more or less falls 
to the bottom, and by stirring with a glass rod the urine 
becomes of a creamy consistence, then albumen is 
present in large amount (1-2 per cent, and more). 

We can make a similar investigation with the boiling 
test. Take a test-tube, fill it a third full of clear, filtered 
urine, and heat it. Should the urine be alkaline, it must 
be acidified with acetic acid. A slight turbidity after 
heating, the urine still being transparent, with only a 
feeble opalescence, indicates a small amount of albumen, 
and only after long standing a light flocculent sediment 
forms. If the urine becomes cloudy by heating, and the 
albumen separates out as flakes, and a layer comes down 



88 ANALYSIS OF THE URINE. 

on the bottom the thickness of a finger, then albumen is 
present in moderate amount. If albumen is precipitated 
in large lumps, and not, as in the other cases, near the 
surface of the fluid, but lower down where the flame 
surrounds the test-tube, and appears to be of a creamy 
consistence, then albumen is present in great amount. 
If we would compare the amount of albumen one day 
with another, we must boil a like quantity of urine in 
similar test-tubes, and compare the mass of the sediment 
after it has well settled. It is more advantageous to 
employ glass tubes of uniform calibre, stopped at the 
lower end with corks covered with waxed paper, pre- 
senting a level surface, measuring the height of the pre- 
cipitate at the expiration of twenty-four hours. 

These are only a few suggestions for the practicing 
physician, but he must be very familiar with the charac- 
teristic reactions in order to draw satisfactory conclusions 
from the latter tests. 

What has been said above applies in like manner to 
those cases in which the albumen is serum-albumen. 

Frequently other modifications of albumen occur, 
of which the most important is globuline (perhaps myo- 
sine). 

Peptone is contained in every albuminous urine. In 
those cases where the temperature is very high, it may 
occur without other albumen in the urine. 

In order to prove the presence of globuline in the 
urine, it must be diluted until it has a specific gravity of 
1*002 ; then add very carefully diluted acetic acid (for 
globuline is soluble in concentrated acid) ; usually a 



THE URINE. 89 

cloudy turbidity results. Iu order to precipitate all the 
globuline, we must pass a stream of carbouic acid gas 
slowly through the solution for from one to two hours. 
After standing some time, the globuline falls as a white 
powder. After pouring off the supernatant fluid, it can 
be tested for albumen by the above methods. If the 
sediment consists of globuline, it will dissolve in a few 
drops of a concentrated sodium-chloride solution. The 
test is best made in a wine-glass or decanting-glass. 
(For further consideration of myosine and paragiobu- 
line, see K. B. Hoffmann, 1. c, 73 and 323.) 

Globuline is observed in great quantity in bladder 
catarrh, acute nephritis, and especially in amyloid, de- 
generated, or waxy kidney ; while from chronic Blight's 
disease it may be very small in quantity or entirely 
wanting. 

2. Sugar. 

The urine sugar, C 6 H 12 6 + H 2 (identical with 
grape sugar), is according to Briicke a constant con- 
stituent of normal urine. It is present in such exceed- 
ingly minute quantity, however, that when we use 
Trommer's test we do not observe the least precipitate 
of yellow cuprous hydrate. We observe that the mix- 
ture simply changes color. In pathological urine, espe- 
cially in diabetes mellitus, we find so great an amount 
of sugar that the urine possesses a sweet taste ; and if 
a piece of cloth is saturated with it, after the evapo- 
ration of the urine the cloth is as if smeared with 
honey. 



90 ANALYSIS OF THE URINE. 

The urine-sugar crystallizes in agglomerated masses, 
which resemble cauliflower in form. 

Of the various tests for sugar, the following are 
generally employed : 

1. Heller's or Moore' 1 s Test. — Pour into a test-tube 
two volumes of urine and one volume of KOH or 
Na OH, and heat to boiling. The earthy phosphates 
fall, and if present in great amount must be filtered 
off. As soon as the fluid becomes hot, a lemon-yellow, 
yellowish-brown, or blackish-brown color appears, ac- 
cording to the amount of sugar present. If we now 
treat this with a few drops of nitric acid, the dark color 
vanishes, and it gives off the smell of molasses. If al- 
bumen is present in great amount, it should be pre- 
viously separated by boiling and filtering. If the urine 
has a dark color, which is seldom the case in diabetes, 
we must render it colorless by acetate of lead (by this 
means a slight amount of sugar falls), or by filtration 
through animal charcoal. This filter must be washed 
with water, for it contains much sugar. 

If the urine has a dark color from the addition of 
KOH in the cold, it is generally due to the biliary col- 
oring matter. This change of color takes place if the 
biliary coloring matters have already decomposed, i. e., 
if the urine does not give Gmelin's or Heller's test for 
the biliary matters. In this case the change of color, 
especially if by the addition of sulphuric acid a very 
dark color is produced, is a good proof of the presence 
of biliary coloring matters. 

According to Badecker, if a urine which has been 



THE URINE. 91 

treated with potassium hydrate (KOH) and allowed to 
stand in the air gradually colors brown from above 
downward by absorption of oxygen, it contains a pecu- 
liar substance which he calls alkapton. This body will 
reduce the copper salt, but not the bismuth salt. Prob- 
ably this body is pyrocatechine. 

Mulder's test gives a beautiful color reaction. If a 
colorless saccharine urine is heated with a solution of 
indigo-carmine, which has previously been made alkaline 
by sodium carbonate, the blue mixture becomes first 
green, then purple-red, and finally yellow. If we shake 
the heated mixture in the air, it takes up oxygen, and 
the color again passes back to blue. If but a small 
amount of sugar is present, the indigo-carmine solution 
only becomes a pale blue. 

2. Trommels Test. — Treat as before two volumes of 
urine with one volume of the KOH or Na OH solution 
(1 part to 3) ; add now drop by drop a solution of 
cupric sulphate (1 part to 10), shaking after each ad- 
dition until the mixture shows a clear beautiful azure- 
blue. Then heat over a spirit lamp. If sugar is 
present, a reduction of the cupric oxide immediately 
takes place, and in the following order : First appears 
a yellow cuprous hydroxide, which soon loses its water 
and becomes the red cuprous oxide. If the urine con- 
tains albumen in large quantity, it must first be sepa- 
rated by coagulation. If we do not remove the albu- 
men, it has a marked influence on the reaction, so that 
the mixture of urine, KOH and Cu S0 4 , does not become 
blue, but of a violet color. If neither sugar nor albu- 



92 ANALYSIS OF THE URINE. 

men is present, we obtain neither an azure-blue nor a 
violet-colored solution, but a turbid grayish-green fluid, 
and by application of heat there is naturally no reduc- 
tion of the cupric salt. 

It is better to employ a solution of sodium-potassium 
tartrate (Rochelle salt) in sodium hydrate (Na OH). If 
we add Na OH to a cupric sulphate solution, cupric 
hydrate (Cu[OH] 2 ) falls. If grape sugar is present, a 
corresponding amount to this will be held in solution. 
If we have added too much cupric sulphate, there is an 
excess of the precipitated Cu(OH) 2 in the solution, and 
the same must be filtered off because it would otherwise 
change to the black oxide of copper (CuO), and thereby 
interfere with the reaction. 

By the employment of the sodium and potassium 
tartrate solution we preserve a clear fluid. 

A large amount of creatine, peptone, etc., may pre- 
vent the reduction to cuprous oxide. 

3. Bottger's Test. — Treat as above two volumes of 
urine with one volume of KOH, and add as much as 
can be taken, up on the point of a penknife of magistery 
of bismuth (a mixture of basic bismuth subnitrate, 
BiO.N0 3 + H 2 0, and some bismuth nitrate Bi(N0 3 ) 3 
+ 5H 2 0), and heat for a short time over a flame. 
Sugar reduces the bismuth salts, so that black suboxide 
of bismuth (Bi 2 2 ) is formed. If only a little sugar is 
present, the white bismuth powder is colored light gray, 
because simply a part is reduced. If but a trace of 
sugar be present, then an excess of the bismuth nitrate 
may conceal the reaction. 



TEE URINE. 93 

If albumen is present, this must first be separated, 
for by the decomposition of the albumen a black sul- 
phide of bismuth is formed, which may be easily mis- 
taken for bismuth suboxide. In order to ascertain to 
what the color is due, we take a sample of the urine 
made alkaline, and add to it a few drops of lead acetate, 
and boil. A black precipitate indicates the presence of 
a sulphur compound in the urine. 

Briicke recommends for the separation of disturbing 
elements Frohn's reagent.* Take equal quantities of 
water and urine in two test-tubes ; to the first add HC1 
until a drop of that reagent no longer produces cloudi- 
ness. In this way we ascertain approximately how 
much HC1 must be added to the urine. After acidifica- 
tion we treat the urine with the reagent and filter (the 
filtrate should then not become cloudy by the addition 
of HC1 or the reagent). Add now an excess of Na OH. 
Should the precipitate of bismuth hydrate be too co- 
pious, a little should be removed by decantation ; then 
we heat a long time, as with Bottger's test. 

Maske gives the following modification : Treat the 
urine with one third its volume of tungstate solution, f 
If proteine substances are at hand, there arises a pre- 
cipitate. After the settling of the same, add a few 
drops more of the reagent to see if all the proteids have 

* Frohn's reagent (iodide of bismuth and potassium): 1*5 grm. of un- 
washed freshly precipitated basic bismuth nitrate is mixed with 20 grms. of 
water and heated to boiling ; then 7 grms. of potassium iodide and finally 
20 drops of HC1, are added. The resulting fluid is orange-red. 

t Crystallized tungstate of soda, 30 parts ; acetic acid (30 per cent.), 
75 parts ; water, 120 parts. 



94 ANALYSIS OF TEE URINE. 

come down. To the filtrate add half the volume of 
concentrated Na OH and a small amount (as much as 
half a pepper-grain) of basic bismuth nitrate, and shake 
well. If this is not colored brown or black, we must 
boil for some time and observe after cooling whether a 
black precipitate has formed. If the precipitate of bis- 
muth is already black before the boiling point is reached, 
we may decide on the presence of diabetic sugar; a 
slight browning, or later becoming black, shows only 
the normal amount of sugar present. If the bismuth 
oxide becomes brown before warming, there is a sulphide 
in solution. We must in this case take a new sample of 
urine, weakly acidify with acetic acid, shake up well 
with some bismuth nitrate, and treat the filtrate as above 
directed. 

Heller's test is the simplest and best, and has besides 
the advantage that one can form an approximative 
determination in regard to the amount of sugar present 
from the intensity of the color. In the second rank 
comes the bismuth test, for if the urine is free from 
albumen there is no other substance present which can 
reduce bismuth. As to Trommer's test, it is least to be 
recommended because, besides sugar, there are in urine 
other bodies which if present in quantity may reduce 
the copper salt. Such are especially uric acid, hippuric 
acid, and the urates. There are many known cases, as 
in febrile processes, in which large quantities of urates 
are present in the urine, where sugar might erroneously 
be supposed to exist, if we relied simply on the yellow 
color of the mixture, without the reduction of the oxide 



THE URINE. • 95 

having been observed. The most reliable tests for all 
cases are the fermentation and the polarization tests, but 
these are generally inconvenient for the practicing phy- 
sician. 

If it is granted that sugar is present in the urine of 
a patient, it is quite important to know how much is 
present and how much is excreted in twenty-four hours. 
The most accurate quantitative methods are spoken of 
later. We may form an approximative conclusion from 
the specific gravity. The higher the specific gravity the 
more sugar should be present. This is true for a simple 
sugar solution, but not for such a compound fluid as is 
the urine. Bence Jones has shown that this method is 
not always to be relied upon, even for an approximative 
test. 

The second method is that of Vogel, which consists 
in determining from the more or less intense color pro- 
duced by the KOH test the amount of sugar present. 
This is quite convenient for the physician. If one pre- 
pares for himself solutions of grape sugar of different 
strengths, and makes the tests with KOH in tubes of 
the same size, he can easily form a scale of the percent- 
age of sugar present which will be fairly satisfactory. 
Treat two parts of each sugar solution with one part of 
KOH, and heat to boiling. A one per cent, solution 
will be colored canary-yellow ; a two per cent, solution, 
dark amber ; a five per cent, solution, the color of dark 
Jamaica rum ; and a ten per cent, solution becomes dark 
brown and opaque, while all solutions of less percentage 
are more or less transparent. As the diabetic urine 



96 ANALYSIS OF THE URINE. 

has a very light color, so by comparison with these 
solutions an approximative determination can be easily 
arrived at, with the help of the known specific grav 
ity. 

Sugar in large amount occurs in only one group of 
diseases, namely, glycosuria. A temporary glycosuria 
occurs after many lesions of the brain, and also a small 
amount in acute febrile processes, after severe burns, 
pneumonia, typhus, rheumatism, and acute encephalitis ; 
in affections of the nervous system, especially of the 
spinal column ; in cachexies and similar processes ; also 
after the introduction of turpentine, nitro-benzole, nitrite 
of amyl, etc. 

Neukomm and Vohl have exceptionally found inosite 
in diabetic urine, either with or in place of grape sugar. 
Also in acute Bright's disease inosite should be found in 
the urine. Many diabetic urines have an odor like 
chloroform. The fresh urine has the same smell after 
standing a short time. It is colored dark reddish-brown 
with iron chloride. In the distillate of such urine 
acetone and alcohol are found, which may arise from the 
breaking up of ethyl diacetate : 

C 6 H 10 O 3 + 2H 2 = C 3 H 6 + C 2 H 6 + C0 2 + H 2 0. 

Ethyl diacetate. Acetone. Alcohol. 

In women, milk sugar (lactose) appears in the urine 
from twenty-four to forty-eight hours after the weaning 
of children, or as soon as from any cause the milk is not 
sufficiently gotten rid of (lactosuria). 



THE URINE. • 97 

3. Leucine and Tyrosine. 

Leucine (C 6 H 13 N0 2 ) and tyrosine (C 9 H n N0 S ) are 
the decomposition products of the albuminous bodies 
and their derivatives. We find both these substances 
in several glandular organs of the body, esj3ecially if 
they have been subjected to certain pathological changes ; 
for instance, in the liver, pancreas, and spleen. In urine 
these substances have as yet been noticed in any great- 
quantity only in acute atrophy of the liver and in a few 
cases of phosphorus-poisoning. Small quantities are 
observed in typhus and small-pox. 

If these substances are present in great quantity in 
the urine (as is generally the case in acute atrophy of 
the liver), the proof of this is very easy. We either 
find the crystalline tyrosine already in the sediment, or 
it separates together with the leucine if we evaporate 
the urine on a water-bath to a small bulk. Sometimes 
both bodies are found in such large amount in the urine 
that they almost supplant the urea. They are easily 
recognized microscopically from the evaporated urine 
by the characteristic form of their crystals. (PL IV., 
A.) 

If these substances are not present in so large quan- 
tity that they separate by simple evaporation of the 
urine, then we take a great bulk of the latter. If rich 
in bile pigments and albumen, the urine is treated with 
a solution of basic acetate of lead, filtered, and the fil- 
trate treated with hydrogen sulphide to remove the 
excess of lead, filtered again, and the clear filtrate evapo- 



98 ANALYSIS OF TEE URINE, 

rated on a water-bath to small bulk. If tyrosine is 
present, it crystallizes beautifully after standing twenty- 
four hours. Leucine, which is much more soluble than 
tyrosine, appears much later. The urine must be as 
fresh as possible to work upon. 

The presence of leucine and tyrosine in large amount 
indicates a considerable destruction of the proteine sub- 
stances. Albumen for the most part accompanies them. 
Often oxymandelic acid (C 8 H 8 4 ) also occurs — a sub- 
stance nowhere else observed, and which is perhaps a 
derivative of tyrosine. 

4. Abnormal Coloring Matters. 

Among the abnormal coloring matters, we are to dis- 
tinguish between those which occur normally in other 
fluids of the body, as the blood- and bile-coloring mat- 
ters, and those which are only found in the urine, as 
uroerythrine, and plant-coloring matters accidentally 
excreted by the same. 

a. Uroerythrine (Harley's urohwmatine). In all 
febrile diseases the urine has a more or less dark 
reddish-yellow color (urina flammed), and an expert is 
able to diagnose in most cases a febrile state from the 
urine alone. This color arises, according to Heller, from 
uroerythrine (as well as from an increase of the normal 
coloring matters). If on cooling a deposit of urates 
occurs, they are mostly rose-colored to dark red. On 
addition of lead acetate to clear urine, the precipitate 
appears flesh-colored or rose-red. Heller calls this red 



THE URINE. 99 

coloring matter of the urine, which colors the brick- 
dust sediment and is also found in solution, uroery- 
thrine. 

This coloring matter should contain iron, but its con- 
stitution and mode of origin are unknown. It is possible 
that in febrile processes, especially such as are accompa- 
nied by blood-dissolution (typhus, septic fever, etc.), a 
part of the blood-corpuscles by their retrograde meta- 
morphosis furnish the material for the formation of the 
uroerythrine. 

The uroerythrine may be regarded as an indication 
of the breaking down of the blood-corpuscles in febrile 
processes. 

Uroerythrine is recognized when present by the color 
of the brick-dust sediment, or, if no sediment be present, 
by the color of the solution, in which if treated with 
acetate-of-lead solution a rose-red or flesh-colored precipi- 
tate falls. Only a little of the lead solution should be 
added, so that the coloring matter shall not be disguised 
by too much of the precipitate. If the urine contains 
the blood-coloring matters, these must be first separated. 
The foam of a urine containing much uroerythrine may 
be yellow as in icterus ; but with the latter the precipi- 
tate from the lead salt is also yellow. 

The earthy phosphates which are thrown down by 
heating the urine with KOH appear gray, while if the 
urine contains blood-coloring matters they are blood-red 
or dichroic. The absence of albumen in the urine, the 
gray color of the earthy phosphates, and the red precipi- 
tate from lead salt, serve as points for the differential 



100 ANALYSIS OF THE URINE. 

diagnosis between uroerythrine and blood-coloring mat- 
ters. 

Uroerythrine occurs in all febrile conditions, even in 
the lightest catarrh, but most frequently in pyaemia, 
liver affections, and lead colic. 

/3. The vegetable-coloring matters. Many vegetable- 
coloring matters, especially chrysophanic acid (in rhu- 
barb and senna leaves), impart to alkaline urine a 
reddish-yellow to deep-red color. These are easily 
recognized from the fact that on the addition of an 
acid the urine loses its color, which returns again upon 
addition of an excess of ammonia. After heating with 
KOH, if a precipitate of earthy phosphate falls, it is 
often colored blood-red, so that one might be induced to 
believe there was blood-coloring matter in the urine. 
The precipitate never appears dichroic, but by long 
exposure to the air becomes violet. 

The fact that the urine loses its color by addition of 
an acid, and regains the red color upon addition of an 
excess of ammonia, and that it contains no albumen, 
distinguishes % this reaction from that of the blood- 
coloring matters and uroerythrine. It is of importance 
for the physician to know this reaction, especially in 
summer, when the urine is apt to have an alkaline 
reaction, and the blood-red appearance to cause alarm. 

7. Blood-coloring matters. The appearance of blood- 
coloring matters in the urine may be from a double 
origin. They may have been excreted by the kidneys, 
or may have arisen from the breaking down of blood- 
corpuscles in the urine. The color of this urine is 



THE URINE. 101 

different according as haemoglobine or methaenioglobine 
is present in the urine. 

From haemorrhage of the large vessels the urine 
contains mostly haemoglobine. By parenchymatous or 
capillary haemorrhage the urine almost always contains 
some methaemoglobine, which imparts to the fluid a 
brownish-red color. The reason that at one time haemo- 
globine alone, and at another with methaemoglobine 
also, appears in the urine, may be due to the fact that 
with capillary haemorrhages, which occur in various 
kidney affections, the blood becomes more slowly and 
intimately mixed with the urine, and is held longer in 
solution at the normal temperature of the body in the 
organism. The temperature and carbonic acid of the 
urine, as well as the lack of oxygen, furnish the essen- 
tial conditions for the change of haemoglobine to methae- 
moglobine. 

In order to prove the presence of the blood-coloring 
matters in the urine, the haemine test is useful. The 
earthy phosphates are precipitated in a test-tube by 
adding KOH with slight warming. The earthy phos- 
phates carry the blood-color substances to the bottom of 
the tube, and consequently do not appear white as in 
normal urine, but blood-red. If but a slight amount of 
blood-coloring matters is present in the urine, the pre- 
cipitate will appear dichroic. 

If an alkaline urine is evacuated, and by heating 
with KOH no earthy phosphates are separated, from 
the fact that they have been already deposited, we may 
by addition of a few drops of the magnesium solution 



102 ANALYSIS OF THE URINE. 

form an artificial precipitate in the KOH mixture, 
which will by warming bring down along with it the 
blood-color substances just as well as do the earthy 
phosphates. 

The precipitate containing the coloring matters of 
the blood should be filtered off and placed upon an 
object-glass, and warmed carefully until the phosphates 
are perfectly dry. Then the hsemine crystals can imme- 
diately be separated. For this purpose a few grains of 
common salt (Na CI) are rubbed into the dried earthy 
phosphates containing the coloring matters ; the excess 
of salt is then blown off the object-glass, and a hair is 
laid across the residue. A glass cover is laid on, a drop 
of glacial acetic acid added, and the slide warmed until 
little bubbles begin to show themselves under the glass 
cover. After cooling, crystals of hsemine can be seen 
under the microscope. Extreme care must be taken in 
this test, upon addition of KOH to the urine, to warm 
but slightly and filter rapidly, to avoid further decompo- 
sition of the blood-coloring matter. When the glacial 
acetic acid is added, air-bubbles form before heating, 
which are simply carbonic-acid bubbles. These are 
allowed to pass away, and then we heat to the bubble 
formation spoken of above, i. e., to the boiling-point of 
acetic acid. The hsemine crystals obtained in this way 
often appear small and imperfectly crystallized, but with 
a high objective they are easily recognized. (PI. V., 
A, 1, and Hoffmann, 1. c, 295.) 

This can be done in another way as follows : Render 
the urine alkaline with Na OH, add tannic-acid solution, 



TEE URINE. 103 

and then acetic acid. The washed and dried precipitate 
is treated for haemine. 

For the proof of blood-coloring matters in urine, 
separate the albumen by heat and coagulation, collect 
the brown coagulum on a filter, dry, and extract with 
alcohol containing some sulphuric acid. Permit the 
alcohol to evaporate. From the residue Teichmann's 
crystals of haemine may be .separated as above de- 
scribed. 

If a spectroscope is at hand, it is very satisfactory for 
the proof of the blood-coloring matters. The urine 
should be diluted and put into a large test-tube, and 
held between the slit and a petroleum lamp. (" Spec- 
tralbild des Methaemoglobin," K. B. Hofmann, 1. c, 277, 
erste Abbildung, Nr. II.) 

The so-called hsematinuria (the passage of blood- 
coloring matters into the urine) occurs with constitu- 
tional diseases, such as scurvy, purpura, scarlatina, etc. 
It is hardly necessary to add that after transfusion of 
blood, after inhalation of hydrogen arsenide, and also 
with true hematuria, soluble blood-coloring matters are 
mixed with the urine. 

B. Biliary -coloring Matters. — Under certain con- 
ditions the coloring matters of the bile may be mixed 
with the urine. The urine more frequently contains 
biliprasine than bilirubine, but not seldom other oxida- 
tion products. If unchanged bilirubine is present in 
the urine, by a simple test we obtain a beautifully 
characteristic color-reaction. If biliprasine is present, 
by the same test we only have a green color. If the 



104 ANALYSIS OF THE URINE. 

biliary coloring matters are further changed, the test 
entirely fails. 

1. GmelvnJs Test. — Into a small test-beaker contain- 
ing the icteric urine we pour a sub-layer (in the same 
manner as we perform the test for albumen, by pouring 
the acid slowly down the side of the glass) of strong 
nitric acid, containing a little yellow fuming nitric acid 
(HN0 3 + N0 2 ). In the zone between the fluids there 
occur from below upward the colors green, blue, violet, 
red, and yellow. The green is predominant, whereas 
the blue often does not appear. This test can also be 
made by adding weaker HN0 3 to the urine in a beaker, 
and then pouring under this mixture a layer of concen- 
trated H 2 S0 4 . 

2. Hellers Test. — Pour into a small beaker-glass 
about 6 c.c. of pure HC1, and drop the urine into it 
until the acid is distinctly colored. Stir this, and 
beneath the mixture pour a layer of pure HN0 3 . In 
the intermediate zone there occurs a beautiful irides- 
cence. If we now stir with a glass rod, the entire mix- 
ture shows the color-changes successively in the same 
order as they had been previously observed between the 
fluids. This may best be seen by transmitted light. 
This test is very delicate, easily applicable, and suffices 
for most cases of urinary investigation. 

To detect the presence of but a small quantity of 
biliary coloring matters, 100 c.c. of urine must be gently 
agitated with 10 c.c. of chloroform in a flask, until the 
chloroform is colored yellow. Strong shaking is to be 
avoided, so that the chloroform will not break up into 



THE URINE. 



105 



small drops, which, will not again resolve themselves into 
a clear fluid. By closing the tube with the thumb and 
inverting the flask, it is easy to pour off about 1 c.c. of 
the colored chloroform into a test-tube containing 10 c.c. 
of pure HC1, when the yellow chloroform drops will 
sink as a colorless fluid to the bottom. If now with 
slight movement we add a little HN0 3 , the chloroform 
at the bottom of the fluid will go through all the spec- 
tral color-changes which are shown in Gmelin's test. 
For the reason that the changes take place very slowly, 
and because acids work but slowly upon biliary coloring 
matters dissolved in chloroform, this reaction is especially 
good for demonstrating the biliary color scale. 

In all reactions upon the unchanged coloring matters 
of the bile, the green color is characteristic. If this is 
not recognized, we can not be sure concerning the pres- 
ence of these coloring matters. Urine rich in indican 
gives also with Heller's test a play of blue, violet, and 
dirty reddish-yellow. The characteristic green of the 
bile matters is, however, not perceived when only indican 
is present. 

If we test for albumen by pouring under the urine a 
layer of HN0 3 in a wine-glass, we see, when the un- 
changed bile-coloring matters are present, a green band 
between the fluids. If albumen also is present, its zone 
is colored green from the biliary coloring matters. 
Urine rich in indican may mislead as to the biliary 
color-reaction. There appears in the same position 
between the fluids an indigo-blue color, which in re- 
flected light may be easily mistaken for green. In such 



106 ANALYSIS OF TEE URINE. 

doubtful cases the biliary matters are to be isolated as 
before mentioned by chloroform and proved by Heller's 
test ; or the urine may be treated with lead solution, 
and the nitrate tested for indican. 

3. Ultzmann\$ Test.— This test simply shows the 
characteristic green color with distinctness and cer- 
tainty. We add to 10 c.c. of urine 3 or 4 c.c. of a pure 
KOH solution (1 part of caustic potash to 3 of water is 
essential), then shake and add an excess of pure HC1. 
The mixture now assumes a beautiful emerald-green 
color. 

If in icteric urine the earthy phosphates are precipi- 
tated by heat and KOH, they are colored brown by the 
biliary coloring matters. 

If the urine already contains altered biliary coloring 
matters (bilifuscine), i. e., such as no longer give the 
reactions of Gmelin's and Heller's tests, their presence 
may be ascertained as follows : A clean white linen cloth 
(or filter paper) is dipped into the urine and allowed to 
dry ; the linen appears colored brown. A further con- 
firmation of the presence of altered biliary coloring 
matters is by a very dark H 2 S0 4 reaction : the urine 
does not appear garnet-red, but almost black. A similar 
reaction is only observed in the presence of sugar and 
blood-coloring matters. Both can be excluded, however, 
by methods already given. 

Finally, if the urine is warmed with KOH and the 
earthy phosphates fall, the urine is colored much darker 
than before the heating, and the precipitate of phos- 
phates is colored brown. 



THE URINE. ' 107 

Biliary coloring matters are found in the urine in 
various pathological processes of the liver, whether or 
not there exists an icteric coloring of the skin. Thus 
icterus can be prognosed one or more days in advance 
by the appearance of the urine. Further, these coloring 
matters are always present in phosphorus-poisoning. 

5. The Bile Acids. 

The bile acids appear very seldom in the urine, and 
when found exist in extremely small quantity. In 
icterus they are rarely found, although the biliary color- 
ing matters are present in large amount. In parenchy- 
matous affections of the liver, on the contrary, which 
are followed by a rapid destruction of that organ, the 
bile acids are undoubtedly present, but in very small 
amount even then. 

It must be accepted that in these cases so much of 
the bile acids are formed that, the blood being unable to 
assimilate them, some are excreted unchanged. 

Sometimes it happens that we are able to prove the 
presence of the bile acids by Strassburgers' method, as 
follows : Dissolve some cane sugar in the urine to be 
tested, dip in a piece of filter paper, and permit it to 
dry. If now we touch the paper with a glass rod 
dipped in H 2 S0 4 (free from HN0 3 ), we perceive a pur- 
ple-violet stripe (a red or reddish brown color is not 
decisive). 

Usually the bile acids must be isolated from a great 
amount of urine and proved by Pettenkofer's test. 






108 ANALYSIS OF THE URINE. 

The method of procedure is very complicated. About 
500 c.c. of urine are evaporated on a water-bath to dry- 
ness, and the residue extracted with alcohol. This solu- 
tion is again evaporated, and the residue again taken up 
with absolute alcohol. The alcoholic solution is again 
evaporated, and the residue dissolved in a little water, 
and treated with lead-acetate solution, avoiding an ex- 
cess ; the precipitate is collected, washed, and dried on 
filter paper. The biliary lead salts are then extracted 
with boiling alcohol. The solution after treating with 
carbonate of sodium is evaporated, and the sodium 
biliary salts thus formed extracted with absolute alco- 
hol. This is now evaporated, and to the very highly 
concentrated aqueous solution of the residue we apply 
Pettenkofer's test, which depends upon the fact that 
when the watery solution of all biliary acids is treated 
with a few drops of a concentrated cane-sugar solution, 
and after that with a few drops of concentrated H 2 S0 4 , 
the solution is colored purple-violet, if we take care that 
the mixture is not heated above 50° C. It is a good 
plan to place, the dish or test-tube in cold water before 
the addition of the H 2 S0 4 ; for otherwise the sugar may 
be carbonized by the H 2 S0 4 and a blackish-brown solu- 
tion ensues. 

The merest trace of these acids may be discovered 
by Neubauer's modification of this. A few drops of the 
solution to be analyzed are evaporated to dryness in a 
porcelain dish over a water-bath. Add now a drop of 
a cane-sugar solution (1 grm. sugar to 500 c.c. water), 
and as much concentrated H 2 S0 4 ; warm them on a 



THE URINE. ' 109 

water-bath until the edge shows a violet color, then 
remove, and the reaction goes on. 

A large number of other substances, as amyl alcohol, 
albumen, and oleic acid, give similar reactions. The 
spectroscope shows, however, an essential difference. 
(S. Hofmann, 1. c, 195.) 

Sometimes, besides the above mentioned substances, 
also appear allantoin, especially after use of tannic acid, 
lactic, acetic, and butyric acids, with acid fermentation, 
benzoic acid in fetid urine, and sometimes also fat and 
soap. 

6. Carbonate of Ammonium. 

All the ammonium carbonate, (NH 4 ) 2 C0 3 , which is 
found in the urine arises from the breaking down of the 
urea. Urea is a carbamid — 

CO< 

X NH 2 

By taking up water, urea is changed into carbonate of 
ammonium — 

( NH 2 ( O.NH 4 

CO-J +2H 2 = CO^ 

(NH 2 (O.KE 4 

This transformation of urea into (NH 4 ) 2 C0 8 is the ex- 
planation of the generation of ammonia either by the 
changes of the urine through decomposition, or, under 
some circumstances, in the bladder. A body adhering to 



110 ANALYSIS OF TEE URINE. 

the mucous membrane of the bladder acts as a ferment 
under certain conditions. This is especially the case in 
bladder catarrh. We find that in most bladder affec- 
tions the urine possesses an alkaline reaction. The 
catarrhal secretion from the pelvis of the Mdney does 
not appear to give rise to an alkaline fermentation of 
the urine, except in very advanced stages. We conse- 
quently find that in pyelitis, in contradistinction to 
bladder catarrh, the urine almost always has an acid 
reaction. If we take two equal parts of fresh normal 
urine and add to one the sediment from a freshly passed 
pyelitic urine, and to the other the sediment from a 
freshly passed cystitic urine, and allow them to stand, 
at first we observe an acid reaction in both urines ; but 
after a short time the urine mixed with bladder secre- 
tion begins to lose its acid reaction, and in two or three 
hours will have become distinctly alkaline, while the 
urine with the pyelitic secretion still possesses an acid 
reaction and does not become alkaline usually until 
twelve to twenty-four hours afterward. 

Carbonate of ammonium appears in the second stage 
of acute exudative processes as the so-called resorption 
urine, which may be regarded as a favorable symptom. 

Carbonate of ammonium may be recognized by its 
odor. Urine containing this shows generally an alkaline 
reaction. Since, however, the alkaline reaction may be 
caused by one of the fixed alkalies, as carbonate of so- 
dium, which may have been taken internally, and we 
are in doubt as to the origin of the alkalinity of the 
urine, we may apply the following test : 



THE URINE. ■ HI 

Pour into a flask of 100 c.c. capacity 15 to 20 c.c. of 
the urine to be analyzed, and close the flask with a cork 
through which is passed a glass tube the thickness of a 
lead pencil. Into this introduce a strip of moistened 
litmus paper, and gently warm the flask on a water-bath. 
If ammonia is present, it will be drawn off with the 
steam, and the red litmus paper will be colored blue. 
In this way we are able to recognize a very small quan- 
tity of ammonia in the urine. Care must be taken that 
the urine does not boil, for then the urea would be 
decomposed and ammonium carbonate would be formed. 
Carbonate of ammonium is present — 

(1.) Usually with the various bladder affections. 

(2.) In the second stage of acute exudative processes 
(resorption urine). 

According to Heller, ammonium carbonate is present 
also in spinal affections and in severe typhus, the urine 
possessing an acid reaction. 



7. Sulphuretted Hydrogen. 

Sometimes we find in albuminous urine, especially 
with bladder catarrh, where a great amount of pus is 
produced, sulphuretted hydrogen (H 2 S). It is formed 
from the decomposition of the albuminous bodies within 
the bladder. Although this may be recognized by its 
odor alone, it can be proved chemically by the same 
means above described for the detection of carbonate of 
ammonium. Instead of the litmus paper that we em- 
ployed above we must substitute a strip of white filter 



112 ANALYSIS OF TEE URINE. 

paper moistened with a drop of a solution of lead or sil- 
ver salts. Upon the addition of the slightest heat the 
H 2 S escapes and colors the white paper in the tube 
black-brown. These urines are betrayed by coloring 
silver catheters black. 

8. Accidental Constituents. 

By accidental constituents of the urine we under- 
stand those bodies which are exceptionally taken into 
the organism and evacuated by the urine. 

Many substances undergo no essential change in the 
organism, including most inorganic compounds, also 
many organic (succinic acid, chloroform, quinine, phe- 
nol, etc.). 

After continued use of the heavy metals and their 
salts, and also after continued employment in contact 
with them (as color- workers, potters, etc.), antimony, 
arsenic, copper, zinc, gold, silver, tin, lead, bismuth, and 
mercury have been found in the urine. 

The alkali salts taken internally appear in the urine 
— the alkali carbonates, ammonium salts, chlorates, 
borates, and silicates of the alkalies, ferro- and ferri- 
cyanide of potassium, potassium cyanide and iodide, etc. 
Sulphur-hepar is excreted as a sulphate. Calcium and 
magnesium salts pass in but very small amount into the 
urine. 

The mineral acids (sulphuric, nitric, phosphoric, etc.) 
become for the most part excreted as the corresponding 
alkali salts. Only carbonic acid occurs free to any great 
extent in the urine. 



THE URINE. • 113 

The metallic bases, which exist in but minute quan- 
tity in the urine, may be separated by the usual quan- 
titative analysis or by electrolysis. Arsenic may usually 
be detected by treating the urine with H 2 S gas and 
applying Marsh's test to the precipitate. 

Many compounds, especially organic, undergo an 
important change in the organism. The aromatic acids, 
for example, are excreted as glycocol combinations, just 
as benzoic acid is excreted by the urine as hippuric, and 
salicylic as salicyluric acid. 

The alkaline carbonates are found in the urine — 

(1.) After their internal exhibition. 

(2.) After use of sodium mineral waters. 

(3.) After a plentiful fruit diet, as the salts of 
vegetable acid are easily changed in the organism to 
carbonates. 

In these cases the reaction of the urine is alkaline. 
Whether this alkalinity is due to the breaking up of the 
urea, or has its origin from the fixed salts, we may 
determine by methods given on p. 44. 

We may also pour 10 c.c. of urine into a porcelain 
dish, and evaporate the same to dryness, dissolving the 
residue in a few drops of water. If this residue gives 
a strongly alkaline reaction, it is due to the presence of 
the fixed alkalies in the urine. If the residue gives an 
acid reaction while the fresh urine has an alkaline reac- 
tion, the alkalinity is due to (NH 4 ) 2 C0 3 , which is de- 
composed by evaporation. If we suspect the presence 
of other alkali carbonates, as well as the unstable am- 
monium carbonate, we must first test for the (NH 4 ) 2 C0 8 



114 ANALYSIS OF THE URINE, 

in a flask as before described, and then test for the others 
in a porcelain dish. 

Iodine is very easily detected. If we add to a little 
urine in a test-tube some carbon disulphide (CS 2 ), and 
drop in bromine water or a small amount of fuming 
nitric acid, and after the addition of each drop close the 
test-tube with the thumb and invert, the violet color 
of the carbon disulphide (or chloroform) indicates the 
presence of iodine. 

We may also add to the urine thin starch paste and 
then a drop of HN0 3 . A blue or bluish-black color 
indicates the presence of iodine. Often, with Heller's 
test for albumen, iodine crystallizes out, partly on the 
side of the glass at the border of the albumen zone, and 
partly on the bottom of the vessel. 

Salicylic acid may be recognized by the violet color 
the urine assumes upon addition of ferric chloride. 
This is best recognized as follows : We add to 1 c.c. of 
a concentrated ferric-chloride solution in a test-tube 
10 c.c. of urine, and note the reaction. A similar reac- 
tion occurs, however, in many diabetic urines. (See 
p. 96.) 

D. THE SEDIMENT. 

Urine Fermentation. 

Normal urine is clear when passed. After standing 
there forms on the bottom or lower half of the urine 
the so-called nubecula, a slight cloud of bladder mucus, 
which is easily distinguished if we hold the glass vessel 



THE URINE. 115 

against a dark background, as the sleeve of the coat, 
especially when in the nxucus-clond epithelium, bacteria, 
or the delicately precipitated urates are suspended. 

A healthy urine, if kept in a perfectly clean vessel 
exposed to the air (but better if air is excluded), will 
remain in this condition a long time (weeks or months). 

Often there takes place in the urine a change known 
as acid fermentation. 

The urine, besides the urate, contains the phosphate 
of sodium. If now this salt of phosphoric acid acts 
upon the sodium urate so that it extracts one part of the 
sodium, there results an acid salt of uric acid, which is 
difficultly soluble and falls to the bottom as a reddish- 
yellow or clay powder. This happens especially at a low 
temperature, but at a high temperature the decompo- 
sition process goes even farther: the uric acid salt is 
deprived of all its base (sodium), and the almost in- 
soluble uric acid separates in beautiful distinct crystals, 
which are more or less brick-red or dark brown, and fall 
to the bottom as a granular powder, a part sticking to 
the side of the vessel and part floating on the surface. 
Sometimes the uric-acid crystals are mixed with the 
amorphous powder of the undecomposed urates — sedi- 
mentum lateritium. 

If while this process is going on we disturb the 
vessel, no free acid is formed. With the urine sediment 
in most cases more or less small or great crystals of cal- 
cium oxalate are mixed (PL III., A). A part of the 
uric acid is in the organism transformed to oxaluric acid, 
which by long standing and exposure to air becomes 



116 ANALYSIS OF THE URINE 

oxidized in the urine to oxalic acid, which appears in 
the sediment as calcium oxalate. (This process, as may 
be understood, does not deserve the name of fermenta- 
tion, though in a few cases a true fermentation appears, 
with formation of acetic acid.) 

When the decomposition of the phosphates and 
urates is ended, there follows after a short time a new 
process. The urine becomes paler ; the crystals of uric 
acid have disappeared ; the acid reaction changes first 
to neutral, then to alkaline; the urine gives off a 
strongly ammoniacal odor, becomes more and more 
turbid, and a whitish sediment falls, which no longer 
consists of urates, but of the phosphates of the alkaline 
earths. By means of the microscope we find that this 
turbidity is not caused by the finely powdered sus- 
pended phosphates, but by a multitude of partly quiet 
and partly ever-moving bacteria. This process is the 
characteristic or alkaline fermentation of the urine 
(PL IV., B). It is based upon the destructibility of 
urea by a peculiar ferment discovered by Musculus 
(Hofmann, 1. c., 400). 

Musculus recommends a paper saturated with the 
ferment as a very sensitive reactive for urea. The 
thick-flowing alkaline urine as it comes from bladder 
catarrh is filtered ; the filter paper which was used is 
washed with distilled water until it has no longer an 
alkaline reaction, dried, and colored with turmeric. The 
urea itself does not react on turmeric, but the urea is 
decomposed by the absorbed ferment, and the paper is 
colored brown by the resulting ammonium carbonate. 



TEE UBINE. 117 

Ammonia can combine with uric acid as urate of 
ammonia, which appears crystallized as single or double 
spheres with a smooth or thorny surface. If the am- 
monia formation goes on, then a part of the ammonia 
joins with the phosphate of magnesia and forms beauti- 
ful crystals of triple phosphates. The phosphate of 
calcium dissolved in acid fluids falls to the bottom in an 
alkaline solution. The sediment then of the alkaline 
urine consists of an amorphous mass of phosphate of 
calcium, together with crystals of triple phosphates; 
at the beginning of the process also urate of ammonium 
is present. 

Blood and pus mixed with urine, as well as un- 
cleansed vessels which have contained fermented urine, 
cause rapid decomposition of the same without having 
previously passed through the so-called acid fermenta- 
tion. Bacteria accompany this process, and well-devel- 
oped mold can be observed on the surface of the urine 
after it has stood for a time, especially on a hot day. 

Classification of the Sediment 

As long as the morbific constituents of the urine are 
distributed throughout the fluid, they produce turbidity 
of the same ; as soon as they sink to the bottom, they 
form the sediment or precipitate. Precipitation occurs 
in different urines with various degrees of rapidity: 
faster in thin than in thick albuminous urines ; more 
quickly if the materials are heavy solids, such as crystals 
of uric acid or the urates ; more slowly if they are light, 



118 ANALYSIS OF THE URINE. 

as epithelium and delicate hyaline cylinders. The con- 
stituents of the sediment are either excreted in their 
present state from the bladder and only need to settle, 
or they may have had their origin in the evacuated 
urine. 

The elements of which the sediment is composed 
are either organic forms — and these appear as well 
in acid as (somewhat changed) in alkaline urine — or 
inorganic, partly amorphous, partly crystalline forms, 
some of which are found in acid and others in alkaline 
urine. 

Accordingly, we may classify all the sediments as 
follows : 

SEDIMENTS. 

I. From acid urine. II. From alkaline urine. 

A. NOT OKGANIZED. 

a. Amorphous: 

1. Urates of sodium and 1. Calcium phosphate. 

potassium. 

2. Fat. 2. Calcium carbonate. 

b. Crystalline: 

1. Uric acid. 1. Ammonium urate. 

2. Calcium oxalate. 2. Triple phosphates. 

3. Cystine. 3. Calcium phosphate. 

4. Tyrosine. 4. Magnesium phosphate. 



THE URINE. 119 



B. OEGANIZED. 

1. Mucus- and pus-corpuscles. 

2. Blood-corpuscles. 

3. Epithelium from the various tracts of the urinary 

apparatus. 

4. Cylinders (or casts) and fibrine coagula. 

5. Spermatozoa. 

6. Carcinomatous tissue. 
V. Entozoa. 

8. Fungi. 

In this series the constituents are arranged according 
to their form and the frequency of their occurrence. 

The Unorganized Sediment 
1. Urates. 

Uric acid is combined in the urine with sodium and 
potassium, and forms in the sediment salts of varying 
composition ; for by a loss of part of the base (as we 
have described in the so-called acid fermentation) an 
acid salt arises, which is difficultly soluble and always 
tends to precipitate. 

The urates are more soluble in warm water than in 
cold, and the neutral salts are more soluble than the 
acid. Therefore it follows that the urates are most 
easily precipitated, if we add a strong acid which will 
deprive the neutral salts of part of their base, forming 
acid salts which are so difficult to dissolve. These 



120 ANALYSIS OF THE URINE. 

become more easily precipitable the colder the fluid and 
the less the bulk of the urine. The formation of the 
urate sediment is favored by the three following con- 
ditions : 

1. Moderate acidity of the urine (by too strong acid 
reaction uric acid is precipitated), or the action of acid 
mineral salts (the so-called acid fermentation). 

2. Concentration of the tirine, whether it be by 
addition of uric acid or by deprivation of water. 

3. Cooling of the wine, which condition may occur 
in the evacuated urine or in the body. 

The neutral alkali urates form an amorphous pow- 
der, which from the accompanying coloring matters 
appears yellowish, grayish-brown, or rose-red to brick- 
red (sedimentum lateritiuni). Under the microscope 
they have the appearance of fine granules joined to- 
gether, resembling moss in structure. (PI. V., B.) 

If there are strips of mucus on the object-glass with 
these granules imbedded, the beginner is liable to mis- 
take them for granular casts. They may be distin- 
guished by a less sharp contour, a less bodily consistence, 
and especially by the reaction of gentle heat. 

The sediment of urates disappears by application of 
heat. Should a residue remain, it is proved to be pure 
uric acid. Upon* addition of some alkali (KOH or 
Na OH) and heat this also disappears. 

From this peculiarity of the urates they are distin- 
guished from pus and the phosphates. The phosphates 
can not be observed, however, if the urine is acid. In 
weakly alkaline urine, especially when made alkaline by 



THE URINE. 121 

KOH, on application of heat the phosphates precipi- 
tate. 

If the nrine contains pus, it will not clear up by 
heating, but on the contrary the coagulated albumen 
renders it more turbid. (The alkalies prevent this 
coagulation.) 

Finally, we may also test the dried sediment by 
means of the murexide test (p. 53), or prove the pres- 
ence of urates by a pretty microchemical test, as follows : 
Add upon an object-glass to the spread-out urates a drop 
of hydrochloric acid, and in a short time observe the 
crystals of uric acid form in the field of the microscope. 

Sometimes we observe in the urine which has under- 
gone the so-called acid fermentation, and is about to 
pass over into the alkaline, that the partly dissolved 
crystals of uric acid are set upon the prismatic crystals 
of acid sodium urate. 

A rare precipitate of crystalline acid urate of so- 
dium is observed sometimes in the strongly acid urine 
of children, the needle-like crystals being arranged in 
groups resembling sheaves of wheat. 

2. Urate of Ammonium. 

The acid ammonium urate is the only urate which is 
found in alkaline urine in connection with amorphous 
calcium phosphate and the triple phosphate crystals. 

Ammonium urate forms brown-colored spheres, which 
may develop singly or as double spheres, or which may 
exhibit a conglomeration of kidney-formed surfaces. 



122 ANALYSIS OF THE URINE. 

The surfaces of sucli forms are smooth, or are studded 
with sharp points, resembling thorn-apples. The pro- 
longations may be long, branching, and bent, thereby 
forming a multitude of similar shapes (turnips, spiders, 
many-rooted teeth, etc.). (PL IV., B.) These forms 
are so characteristic that the observer after using the 
microscope remains no longer in doubt as to the nature 
of the sediment. 

The quantity generally admits of a few microchemi- 
cal tests. 

If a drop of HC1 is allowed to now under the glass 
cover, the original bodies disappear, and after a short 
time we see the very small rhombic crystals of pure uric 
acid formed. If KOH is added instead of HC1, we 
observe the formation of bubbles from the liberated 
ammonia. The urate of ammonia gives like the others 
the inurexide test (p. 53). 

3. Uric Acid. 

The appearance of uric acid in the urine is in part 
dependent upon the same circumstances as the urates. 
Normally we find crystals of uric acid at the end of the 
so-called acid fermentation, also in concentrated urine, 
especially on summer days, when the higher temperature 
prevents the deposition of the urates. Finally, a patho- 
logical excess is found in those cases where the water 
and the alkalies do not suffice to retain it in solution. 

The primary form of uric-acid crystals is that of 
rhombic plates with blunt rounded corners. This shape 



TEE (IL'INK • \-i:>> 

is known as whetstone crystals. The crystals may be 
small and singly developed Sometimes rows of these 
crystals are deposited oh accidental impurities, as threads 
or hairs, and thus form Long cylinders. In other cases 
the single crystals are developed and joined to foreign 
matters, where they are arranged upon the edges (fan- 
shaped) or upon the faces (an tiles). Besides the whet- 
stone crystals, we often find tub-shaped or long pointed 
crystals joined together in a rosette. (PL II., I>.) 

The rough and pointed forms of uric acid have a 
great practical significance, inasmuch as they are almost 
always an accompaniment of renal calculi. (Ultzmann, 
"Ueber Earnsteinbildung," in "Wiener Klinik," 1875, 
5 Heft.) 

These; forms occur only in strongly acid urine. If 

the acid urine is neutralized by the internal administra- 
tion of fixed alkalies, the forms of the crystals are 
changed, the pointed forms becoming the normal whet- 
stone-shaped crystals. 

The rough and pointed forms of the crystals occur 

in the urine sediment of pyelitis calculosa, and are fre- 
quently accompanied by albuminuria (hyperemia of 

the kidney) and hematuria. 

We also find these forms present without pyelitis or 
albuminuria. When this is the case, micturition is 
sometimes painful. 

In every case the uric acid is colored light yellow, 
brown-red, or dark brown by the accompanying coloring 
tnatters. 

The crystals are generally formed so Large that they 



124 ANALYSIS OF THE URINE. 

appear on the bottom of the vessel as a glistening brick- 
red sand, which may often be seen by the unaided eye. 
This sediment dissolves on heating with caustic 
alkali ; partly because some urates are formed, while 
the remainder of the acid is deoxidized. The sediment 
gives finally a beautiful murexide reaction. 

4. Calcium Oxalate. 

Oxalic acid has a strong affinity for calcium. Since 
calcium salts are present in the urine, the oxalic acid 
which is excreted by the kidney or forms in the urine is 
observed in combination as calcium oxalate. These 
crystals result, as already mentioned, from the acid fer- 
mentation together with uric acid. The shape of the 
calcium oxalate is very characteristic. The crystals are 
generally quadrilateral octahedrons which have a strong 
refractive power. Sometimes they appear as small but 
distinctly angular dots, and sometimes as rectangular 
plates whose angles are joined by diagonal lines, causing 
the envelope appearance. Some appear oblique. Be- 
sides these principal forms, we sometimes observe dumb- 
bell crystals. (PL III., A.) As these crystals have a 
low specific gravity, they appear only after a long time 
in the sediment — from twelve to twenty-four hours; 
after this time has elapsed we must carefully decant 
and look for the small four-cornered dots. 

The characteristic form of the crystals admits of no 
confusion. The only crystals with which they may be 
confounded are the triple phosphates. In the first place, 



THE URINE. 125 

however, the caleium-oxalate crystals are never as large. 
Secondly, calcium oxalate occurs in acid urine, triple 
phosphates appear in neutral or alkaline. Finally, 
acetic acid dissolves the triple phosphates, but has no 
action on the calcium oxalate. 



5. Cystine, 

Cystine forms regular hexagonal tables of varying 
size. These occur singly, or we find a large plate at 
the bottom, and smaller and smaller plates as the series 
ascends ; we also observe a shingle-like series. Some- 
times a large crystal breaks, showing the hexagonal 
cleavage to be still preserved. Small, imperfectly devel- 
oped crystals form irregular lumps. Often the corners 
of the plates are rounded as if melted off. The crystals 
are always colorless. (PL VI., A.) These crystals can 
only be confounded with a pure, colorless, rarely occur- 
ring form of uric acid. This similarity is observed when 
the cystine is precipitated by acetic acid ; for, when uric 
acid is precipitated in the same manner, the forms are 
similar six-sided plates but generally not as regular. 

In order to ascertain if our crystals under the micro- 
scope are cystine, we carefully allow a drop of ammonia 
to flow under the cover-glass. Instantly the crystals of 
cystine vanish, while uric acid without the application 
of heat remains unchanged. As soon as the ammonia 
has evaporated, the cystine again crystallizes. The 
reprecipitation is assisted if we add a drop of acetic acid 
to the ammoniacal solution. 



126 ANALYSIS OF THE TJRINE. 

A second test consists in treating the cystine crystals 
with a drop of hydrochloric or oxalic acid. Cystine 
dissolves, while the uric acid will remain unchanged. 

The form of the crystals and their insolubility in 
boiling water prevent cystine from being confounded 
with the urates. 

Cystine is soluble in ammonia, but insoluble in car- 
bonate of ammonia. In case the cystine is held in solu- 
tion in the acid urine at the beginning of the alkaline 
fermentation, it is precipitated like an earthy phosphate 
by the carbonate of ammonia generated. 

From the earthy phosphates and triple phosphates 
cystine is easily distinguished by chemical tests, and by 
the microscope, which shows the earthy phosphates as 
an amorphous powder, while the triple phosphates pre- 
sent an entirely different form of crystals. 

Acetic acid dissolves the earthy phosphates, but the 
cystine is unaltered by it. But, if it happens that by 
addition of acetic acid and heat the greater part of the 
sediment dissolves and but a trace remains, this should 
be brought under the microscope ; and, if hexagonal 
plates appear, they should be treated in the above de- 
scribed manner with ammonia and hydrochloric acid, to 
distinguish the cystine from uric acid. 

If we dissolve cystine in KOH, warm, add water, 
and then a solution of nitro - prusside of sodium 
(Na 2 (CN) 5 (NO)Fe // ), the mixture becomes violet. This 
reaction also will show albumen or any other compound 
containing sulphur in the dyad form. 

The urine in which we iind cystine is mostly pale 



THE URINE. 127 

When putrefying it develops, besides the animoniacal 
odor, that of hydrogen sulphide, which in all proba- 
bility occurs as a decomposition product of the cys- 
tine. The sediment of cystine occurs in connection 
with cystine stone, and also independently of it. It 
appears white or dirty yellowish-gray, often with an 
abundance of triple phosphates and phosphate of cal- 
cium ; in acid urine, with calcium oxalate. 

This sediment seldom occurs with us, but it some- 
times happens that many members of a family suffer 
from cystinuria. 

6. Leucine and Tyrosine, 

Both of these substances are usually found together 
in the urine, but mostly in solution. Simple evapora- 
tion serves to produce a sediment (p. 97). Tyrosine 
sometimes appears as a sediment without this treatment. 

Under the microscope leucine appears as spheres of 
various sizes, more or less colored, and having the ap- 
pearance of large drops of fat. They are sharply 
defined, and show in a favorable light fine radiating 
stripes and also delicate concentric lines. 

Tyrosine forms very fine short needles, made up into 
sheaves or bundles crossing each other at various angles. 
(PL IV., A.) 

Sometimes leucine spheres are distributed throughout 
this formation. The addition of a drop of ether will 
prevent confusion of the leucine with fat-globules, for 
fat is dissolved by the ether. The crystals are soluble 
in caustic alkalies, but not in cold mineral acids. 



128 ANALYSIS OF TEE URINE. 

Tyrosine crystals can be identified in two ways, by 
Piria's and Hoffmann's tests. The first method consists 
in placing a small amount of the sediment in a watch- 
glass, and moistening with a few drops of concentrated 
sulphuric acid; after an interval of twenty to thirty 
minutes add some water and neutralize the solution with 
calcium carbonate as long as it effervesces, and then 
filter. If, on the addition of ferric chloride which is 
free from acid, a violet color is produced, tyrosine is 
present. 

The second method is still simpler. The sediment 
is diluted with water and boiled ; to the boiling fluid 
add a few drops of mercuric-nitrate solution. If a red 
precipitate falls and the supernatant fluid is rose- or 
purple-red, tyrosine is present. Leucine and tyrosine 
occur in the urine very infrequently, seldom otherwise 
than with acute yellow atrophy of the liver and phos- 
phorus-poisoning. 

7. Fat 

The fat-globules which float on the surface of many 
urines must not be regarded as coming from the urinary 
organs. We often find that the patient has been cathe- 
terized, and the fat has come from the oil used to lubri- 
cate the catheter. We must also be careful regarding 
the finely divided fat-globules under the microscope ; 
they are apt to be from unclean object-glasses, or 
from the urine having been collected in greasy bottles 
which have previously contained hair oil or some fatty 
emulsion, medicines, etc., or to be caused by milk 



THE URINE. ■ 129 

having been emptied into the vessels nsed for the 
urine. 

The assertions that entire fat-globules appear in the 
urine with excessive fatty degeneration of the kidney, 
we are unable to confirm by our personal observation. 
It seems very improbable, since the parts of the kidney 
affected by fatty degeneration do not secrete urine, so as 
to allow the fat-globules to enter. This view is strength- 
ened by a careful dissection of the parts. An emulsion 
of fat is observed in the chylous urine of the tropics 
(galacturia), partly causing its turbidity. The turbidity 
from these causes is cleared up by shaking with ether. 
In such urine the sediment is peculiar ; as the specific 
gravity of the urine is higher, the sediment will rise 
to the surface as a cream. The fat shows under the 
microscope various large spheres with sharp contours. 
Ether dissolves it. Cholesterine occurs sometimes along 
with the fat, but very rarely, and for the most part in a 
crystalline form, recognized by the clear, large rhombic 
plates. In Europe galacturia occurs very seldom. 

8. Earthy Phosphates. 

a. Amorphous. — In ammoniacal urine we find regu- 
larly a heavy precipitate of grayish-white sediment, 
which the beginner often mistakes for pus. This sedi- 
ment is the precipitated earthy phosphates, i. e., calcium 
and magnesium phosphates. As we have said, these 
salts are only soluble in acid fluids, and consequently 
must have been precipitated from the time when the 



130 ANALYSIS OF THE URINE. 

urea changed to carbonate of ammonium, thereby ren- 
dering the urine alkaline. Under the microscope the 
earthy phosphates appear as granules of various sizes, 
which do not form the mossy groupings that characterize 
the urates. Their identification chemically is very easy. 
The urates, with the exception of urate of ammonium, 
occur in acid urines, while the earthy phosphates (the 
crystalline calcium phosphate which occurs in acid urine 
being excepted) are found only in alkaline urine. The 
reaction with litmus settles the question as to whether 
we have to do with urates or phosphates. By heating, 
the urates disappear while the sediment of the phos- 
phates increases. By addition of KOH or Na OH the 
urates dissolve, while the phosphates remain unchanged. 

The distinction bet ween. phosphates and pus is shown 
in Donne's test. (P. 139.) 

All circumstances which lead to alkaline fermenta- 
tion of the urine, or cause the alkalinity of the same, 
tend to the formation of the sediment described, which 
is precipitated in mass proportional to the amount of the 
earthy phosphates in solution. 

Only exceptionally, with bladder catarrh or after the 
use of a great amount of alkalies, is the urine alkaline 
upon evacuation. In these cases it is already turbid 
from the precipitation of the earthy phosphates thrown 
down in the bladder. Generally the turbidity appears 
only a shorter or longer time after evacuation of the 
urine. These amorphous earthy phosphates are often 
mixed with a beautiful combination of magnesium phos- 
phate with ammonium — the so-called triple phosphate. 



THE URINE. 131 

h. Crystallized calcium phosphate. — Crystalline cal- 
cium phosphate, of the formula P0 4 HCa + 2H 2 0, is 
found in pale weakly acid urines, which have a tendency 
toward alkaline fermentation. 

This sediment appears with some persons as an 
individual peculiarity oftener than from other causes. 
We have observed individuals living under healthy 
normal conditions to have in summer a daily sediment 
of crystalline calcium phosphate in the urine. 

Under the microscope the crystals appear club- 
shaped, with broad oblique bases. They may be iso- 
lated, or may lie over one another, the points converging 
together, often forming a rosette, the periphery being 
formed by the bases of the crystals. 

In some cases the crystals do not simply form cir- 
cles, but make up segments of spheres. (PI. III., B.) 
(Other forms are described in K. B. Hoffmann's " Zoo- 
cheroie.") 

The forms of the crystals are so characteristic that 
confusion is hardly possible. The triple phosphates 
which may accompany them in later stages of alkaline 
fermentation have no points, and moreover form no 
bouquets or rosettes. 

From uric acid this sediment may be distinguished 
by the fact that it is colorless and disappears on addi- 
tion of acetic acid. 

9. Magnesium Phosphate. 

In neutral or weakly alkaline urines, which we ob- 
serve after the internal use of the fixed alkali carbonates 



132 ANALYSIS OF THE URINE. 

or mineral waters containing them, appear long quadri- 
lateral tables of basic magnesium phosphate, Mg 8 (P0 4 ) 2 
-|- 17H 2 0, two opposite angles of which have been 
truncated. If we allow a drop of a solution of commer= 
cial ammonium carbonate, in five parts of water, to flow 
over these crystals beneath the cover-glass, they become 
opaque, and appear like rough leather gnawed on the 
edges. 

Calcium phosphate does not become opaque, and is 
more slowly affected by such treatment. Triple phos- 
phates are not altered. 

This sediment is very rare, and can only develop in 
urine which is strongly concentrated and is originally 
neutral or alkaline. If the urine becomes alkaline from 
the urea decomposition, there is naturally no magnesium 
phosphate, but we have ammonio-magnesium phos- 
phate. 

10. Triple Phosphates. 

These appear as large, clear, refracting crystals, with 
distinct smooth surfaces and sharp edges. Among the 
many combinations of the rhombic and very frequently 
partially amorphous shapes, the coffin-lid crystals are 
the most common. (PI. III., B.) They might be con- 
fused only with sodium chloride or calcium oxalate; 
but sodium chloride only appears as crystals in evapo- 
rated urine. From calcium oxalate they may be distin- 
guished by adding a drop of acetic acid ; if the sediment 
dissolves, it is triple phosphates; if it remains un- 
changed, it is calcium oxalate. The conditions under 



THE URINE. . 133 

which these occur have been spoken of under earthy 
phosphates. 

11. Calcium Carbonate. 

The urine of most herbivora is already cloudy when 
evacuated. The turbidity arises from the mass of the 
excreted calcium carbonate. Only exceptionally is such 
a condition found in man, though it sometimes occurs a 
short time after the urine is evacuated. The causes of 
this are somewhat obscure. 

This sediment does not come down by itself, but in 
connection with the earthy phosphates, forming a more 
or less fine grained powder, and sometimes dumb-bell 
crystals. (PL VI., B.) We can recognize this precipi- 
tate by its solubility with effervescence on addition of 
mineral acids. This may be observed under the micro- 
scope. If, by placing a thread or a hair under the cover- 
glass, we allow a drop of HC1 to reach the sediment, then 
we see gas bubbles of carbonic acid developed. This 
reaction is never observed with pure earthy phosphates. 
The sediment must be previously washed carefully with 
water on a filter to remove any ammonium carbonate 
(which with acids would also cause effervescence). 

Organized Sediment 

1. Mucus. 

Considerable mucus may be contained in the urine 
and not be noticed, because of its transparency, and the 
slight difference of its refractive power from that of the 



134 ANALYSIS OF THE URINE. 

urine. Only after long standing, when the urates begin 
to come down, when the urine contains more epithelium 
than usual, or when there is a rapid and considerable 
development of bacteria, does the mucus form the before - 
mentioned nubecula. 

If these conditions are not fulfilled, we color the 
urine. 

If there is no albumen in the urine, we precipitate 
the mucus with alcohol to which some tincture of iodine 
has been added, as a stringy mass. Or the mucus may 
be precipitated by acetic acid to which has been added 
a little of a solution of iodine dissolved in potassium 
iodide. The acetic acid causes a turbidity of the mucine 
in solution, which is not affected by an excess of this 
acid, but which vanishes upon addition of a couple of 
drops of HC1. 

If the turbidity of the urine disappears by applica- 
tion of heat, we know it was not due to mucus, but to 
the urates. Mucus has no characteristic form under the 
microscope ; we find only crystals of oxalate of lime and 
uric acid, as well as mucus-corpuscles (young cells) or 
bladder epithelium which have been held in suspension 
by the mucus. 

Mucus coagulated by acetic acid, however, shows 
under the microscope a granulated mass, for the most 
part striated bundles, sometimes simulating casts and 
cylinders. 

In women we generally find a much greater nube- 
cula, because the urine is usually mixed with a great 
quantity of vaginal mucus, especially with nuor albus. 



THE URINE. , 135 

Since mucine only swells in water and undergoes no 
real solution, we may separate it from the urine by 
nitration. The mucus remains on the filter, and appears 
there when dry as a glistening varnish. Urines contain- 
ing much mucus filter badly, for the reason that the 
pores of the paper are stopped. 

2. Epithelium. 

We have already mentioned the young cells as 
mucus-corpuscles. Other cells appear in the urine 
which serve as an epithelial covering for the mucous 
membrane of the urinary apparatus, or as the proper 
glandular tissue of the kidneys. 

Manifold as the forms of the epithelial cells appear, 
if we examine the various parts of the urinary apparatus, 
we do not find all these forms represented in the urine. 
The urine, as a fluid containing various salts in solution, 
works a change upon the epithelial cells. Three forms 
may with certainty be distinguished : 1. Kound cells ; 
2. Conical and caudate cells ; 3. Flat cells. 

1. The round cells arise from the tubules of the kid- 
ney, and from the deeper layers of the mucous mem- 
brane of the kidney -pelvis. In their original form they 
are more or less oppositely flattened, corresponding to 
their position beside one another. (PI. I., A, 1.) Un- 
der the influence of the urine they swell and become 
globular. They have a clearly defined nucleus, and are 
by this easily distinguished from the pus-corpuscles 
which also appear in the sediment. The pus-cells are 



136 ANALYSIS OF TEE URINE. 

uniformly granulated, and show their nuclei with dis- 
tinctness upon addition of acetic acid. The epithelial 
cells contain but one nucleus, the pus-cells two, three, 
and sometimes more; besides, the epithelial cells are 
larger. 

In acid urine the epithelial cells are rather long, but 
if the urine is neutral or alkaline, they appear greatly 
swollen, nearly hyaline, the granular protoplasm entirely 
surrounding the nucleus ; after a time they become 
wholly dissolved. The epithelium of the male urethra 
is very similar to the kidney epithelium, so that it is 
difficult to distinguish one from the other under the 
microscope. (PL I., B, 1.) The distinction is usually 
based upon the chemical constitution of the urine. If 
the urine contains albumen, the round cells are due to a 
desquamation from the urinary tubules. If albumen 
is not present, the round cells are probably from the 
urethra. 

The epithelium of the prostate, Cowper's, and Lit- 
tre's glands is similar to that of the urethra, and can 
not be distinguished from it microscopically. With 
mucus and pus the epithelium forms the so-called gonor- 
rhoea! threads. (PL VI., A, 2.) 

2. The conical and caudate cells have their origin in 
most cases in the pelvis of the kidney. Very delicate 
cylindrical cells come also from the accessory organs of 
the male urinary apparatus, though they are of rare 
occurrence. The cells are generally twice as long as 
broad, and are smaller at one end than at the other. 
The caudate cells may have a prolongation on one end 



TEE URINE. • 137 

(unipolar), or they may have spindle-shaped prolonga- 
tions on both (bipolar caudate cells). (PL I., A, 2.) 
The presence of these cells must not be regarded as an 
indication of a neoplastic growth, as is stated in the 
older writings. 

3. The flat cells arise either from the bladder or 
the vagina. They are most irregular, polygonal with 
rounded corners, and have a sharply defined dark 
nucleus nearly in the centre. This nucleus bulges out, 
as may be seen when the cell is standing on its edge, 
making the cross-section appear like a spindle-cell. (PL 
I, B, 2.) 

It is difficult sometimes to distinguish the bladder 
epithelium from that of the vagina. The bladder 
epithelium is more delicately formed, and generally 
appears singly ; the epithelium of the vagina is some- 
what coarser, has sometimes a warped surface, and is 
almost always cast off in great cohering shreds ; fre- 
quently the scales are arranged in layers, an appearance 
never occurring in bladder epithelium. (PL I., B, 4.) 

The yellow color of the nuclei of various epithelial 
cells with icterus is interesting. If we now allow a 
drop of fuming nitric acid to flow under the glass cover, 
we observe the nuclei to pass through the color changes 
of Gmelin's test (green, blue, violet, etc.) (Ultzmann). 



3. Pus-corpuscles. 

The pus-corpuscles of the urine are quite similar in 
appearance to those of a suppurating wound. They are 



138 ANALYSIS OF TEE URINE. 

round cells twice as large as blood-corpuscles, with a 
uniformly granular exterior which surrounds the nuclei. 
The nuclei may be exhibited more distinctly by the 
addition of a drop of acetic acid under the cover-glass : 
the granulation vanishes, the corpuscle swells, and the 
several centrally placed nuclei become visible. Besides 
this usual form, there is another of rare occurrence, in 
which the corpuscles are not round, but have various 
prolongations which show amoeboid movement. (PI. 
VII., B.) 

The pus-corpuscles are changed, especially in ammo- 
niacal urine, under the influence of carbonate of ammo- 
nium. They swell up and coalesce, showing under the 
microscope a homogeneous mass, in which the nuclei 
alone are distinguishable. Such pus forms a vitreous, 
slimy mass, which on pouring flows out as a whole, like 
albumen when poured from one vessel to another. 

This must be distinctly emphasized, lest the beginner 
fall into error in supposing that such a slimy mass is 
mucus or albumen. The latter does not form a sediment 
under any conditions, and mucus never forms a like 
cohering mass. If pus is in the urine, pus-serum and 
albumen must also be present. We may always obtain 
the albumen-test, which is not the case with mucus. 

The amount of pus-corpuscles is various. Often the 
urine contains so few that they (forming no sediment) 
escape the unaided eye. In some urines so much pus is 
present that a sediment several fingers high is formed of 
a yellowish or grayish white color. 

A confusion with the urates is possible in acid 



THE URINE. • 139 

urines, and with the phosphates in alkaline. We have 
already described the tests for the urates. The phos- 
phates disappear on addition of a few drops of acetic 
acid ; pus does not. 

Donne } s test permits the distinction without the aid 
of the microscope. Pour the urine from the sediment, 
and add a little piece of caustic soda or potassa. If the 
sediment consist of pus, then it will lose its white color, 
becoming greenish and vitreous, first stringy, then 
thicker, until finally it forms a cohesive lump. It has 
in this manner taken on the appearance of pus in a 
strongly alkaline urine. Since no other body in the 
urine can give this reaction, it is a perfectly safe method 
of distinguishing pus. If the amount of pus is scanty, 
one can not expect to obtain the cohesive lump, but on 
the contrary the sediment disappears and the fluid be- 
comes vitreous and stringy. 

With the sediment are mixed broken-down pus-cor- 
puscles (detritus), and frequently blood-corpuscles, epi- 
thelial cells, etc. 

4. Blood- Corpuscles, 

Blood-corpuscles in the urine may be distinctly rec- 
ognized when present in but small amount. If the 
urine is tinged a brownish red, and the suspicion arises 
that blood-coloring matters or corpuscles are mixed with 
it, we allow it to stand for some time, in order that the 
light and sparingly present blood-corpuscles may form a 
sediment (often but a trace), which is colored a beauti- 
ful red. 



140 ANALYSIS OF TEE URINE. 

In acid urine the blood-corpuscles retain their char- 
acteristic form for a long time. They exhibit small 
disks, which show a central shadow corresponding to 
the depression. If the blood-corpuscles stand on their 
edges, they appear bi-concave. They are always single 
(except in profuse haemorrhages from the bladder, when 
they form rouleaux), and appear reddish with a slight 
greenish tinge. 

This original form of the blood-corpuscle undergoes 
many changes, brought about by the nature of the men- 
struum in which the corpuscles are distributed. If the 
urine is very dilute, especially if it has begun to be am- 
moniacal, the corpuscles swell, the depression disappears, 
and they become spherical, appearing somewhat smaller 
than before. The central shadow vanishes with the 
depression, and instead the corpuscle has a peripheral 
shadow by which it is recognized as a sphere. 

By longer exposure to the above influences, the cor- 
puscle becomes more indistinct and appears as a delicate 
bubble, which then becomes but a mere shadow in the 
field, finally disappearing. 

By treatment with a neutral-salt solution the blood- 
corpuscles become smaller and jagged. These jagged 
forms are observed in the urine, often in connection with 
the normal. The corpuscles appear to have produced 
within themselves small crystals whose ends cause the 
limiting membrane to become distorted. (PL V., A, 2.) 
Sometimes the corpuscles are not round but oval, and 
are of various sizes in the same urine ; sometimes cup- 
shaped. 



THE URINE. • 141 

In hematuria which accompanies parenchymatons 
affections of the kidney and bladder, we find almost 
always spherical corpuscles of different sizes. Quite 
small, even dust-like blood-corpuscles (microcytes) occur 
in such cases with normal and greater forms (macro- 
cytes). 

No matter how small an amount of blood-corpuscles 
is present, it is always possible to prove the presence of 
albumen in connection. 

If the blood-corpuscles have been dissolved in an 
ammoniacal urine, we may test for the coloring matters 
(haamo- or methaamo-globine), as described on page 68. 

Regarding the origin of blood-corpuscles in the urine, 
the subject is treated of in Chapter VIII. 

5. Cylinders. 

The identification of cylinders plays a most impor- 
tant part in the diagnosis of kidney diseases; for by 
their form they betray their place of origin in the urin- 
ary tubules. In the investigation of the urine, the 
greatest care must be taken that these be not over- 
looked. By their low specific gravity they remain for a 
long time suspended in the urine. To this may be 
added the circumstance that their appearance is gener- 
ally accompanied with albuminuria, and in the albu- 
minous fluid their precipitation is very slow. 

The precautions necessary for the investigation of 
these forms are as follows : The urine must be permit- 
ted to stand for several hours, then carefully decanted, 



142 ANALYSIS OF THE URINE. 

and the residue shaken up in a pointed sediment-glass, 
and allowed to stand again one or two hours. The last 
drops of the sediment should be brought under the 
microscope. One should never be satisfied by one ex- 
amination, as the number of cylinders is always small 
and may be overlooked on hasty investigation. While, 
on the one hand, we must exercise caution not to over- 
look the cylinders, on the other hand we must not mis- 
take for them materials of an entirely different nature. 
Beginners are apt to see granular cylinders in every 
accidental cylindrical arrangement of the phosphates or 
urates, especially if imbedded in stripes of mucus. 

Although cylinders are generally accompanied by 
albuminuria, there is albuminuria with which no cylin- 
ders are found, and there are isolated cases in which 
cylinders are present without contemporaneous albu- 
minuria. Examples of the first case are the albuminuria 
of interstitial nephritis, of amyloid kidney, and renal 
stasis; as an example of the second condition, severe 
inflammatory processes are to be mentioned, in which 
the cylinders precede albuminuria from twelve to twen- 
ty-four hours. 

Among the numerous cylinders the chief forms 
(partly passing into one another) are the following : 
1. The ordinary fibrine cylinder; 2. The fine granulated 
cylinder ; 3. The hyaline cylinder ; 4. The waxy cylin- 
der; 5. The epithelial casts and cylinders; 6. The so- 
called uric acid cylinder ; 7. The bacteria and micrococci 
cylinders. 

1. The ordinary jibrine-cylinders are roll-formed. 



THE URINE. ■ 143 

often spirally twisted clots, with a sharp contour and of 
a light yellow to brown-yellow color. Their calibre 
exceeds that of the other casts, so that they may be 
regarded as having their origin in Bellini's tubes (see 
Fig. 2), near their outlet upon the papilla ; frequently 
the epithelial cells adhere to them. The blood -cylinders 
may be regarded as a lower form of the fibrine-cylinder ; 
these consist of clotted blood, and arise from rupture of 
the glomeruli. These are always dark brown, and ap- 
pear to consist of a compressed clot of blood-cells. 
Sometimes we observe on one part of a cylinder a 
iibrine-clot, while the other is covered with blood- 
corpuscles. This form is always accompanied with 
isolated blood-corpuscles in the sediment. (PL VII., 
A,l.) 

2. The fine dark-granuled cylinders are smaller than 
those described above. They appear under the micro- 
scope as a solid plug from the more remote urinary 
tubules. They have sharp contours, and appear, as 
their name implies, finely granulated throughout ; they 
are rounded off on one or both ends like a finger, ap- 
pearing uniformly of the same calibre, or constricted as 
if strangulated. They may be shaped at one end like 
the neck of a bottle. In the granulations many modifi- 
cations are to be observed : in some places the granules 
are coarse, and in others the casts seem to have almost 
lost their granulations and to have become hyaline. 
Sometimes fat-globules are mixed with the granulations. 
Upon the addition of acetic acid, in some cases the 
granulations disappear, so that the cylinder becomes 



144 ANALYSIS OF TEE URINE. 

clear; in other cases this has no influence whatever. 
The color of the granulated cylinders is a pale, dirty 
grayish yellow. (PL VII, A, 2.) 

Both these forms of casts remain a long time un- 
changed in* acid urine, while in alkaline they gradually 
become more indistinct and finally disappear. 

3. The hyaline cylinders are of the same size as the 
granular casts, or they may be smaller. They are some- 
times straight and sometimes curved; the length is 
often considerable. While at times the appearance of a 
solid body is unmistakable, again they appear as very 
delicate tubes cylindrically formed, sometimes ribbon- 
shaped. Frequently we find spirally twisted cylinders, 
with one or more turns. (PI. VII., A, 3.) In the first 
and greater forms a distinct contour is visible, while the 
last mentioned forms are difficult to recognize from the 
surrounding medium, and under the microscope they 
only appear as a shadow. In such cases it is advisable, 
in order to bring out their form, to add a drop of iodine 
dissolved in potassium iodide solution, or aniline violet, 
by means of which the cylinders appear respectively 
yellow or blue-violet, and may be better distinguished 
from the paler surroundings. They show generally no 
trace of granulation, but are perfectly transparent. 
From the narrowness of the ribbon cylinders, they are 
supposed to come from the smaller branches of the 
urinary canals, perhaps from the fine ascending loops of 
Henle. The hyaline cylinders disappear soon in alkaline 
urine. 

4. The waxy cylinders are about the width of the 



THE URINE. 145 

granular, perfectly clear and strongly refractive, so that 
their contour is as sharply defined as the triple phos- 
phates or. similar clear crystals. They are straight, 
broken, or curved. Their surface is often wavy, as if 
they were made up of coalescent colloidal nodules. In 
places they show deep indentations, as if the gelatinous 
mass had yielded to pressure. They give the amyloid 
reaction, and are tougher than the other cylinders. This 
form of cylinder is of rare occurrence, and has been 
found only with amyloid degeneration and tuberculosis 
of the kidney. (PL VII., A, 4.) 

5. The epithelial casts and cylinders are processes by 
which the epithelial coating of the urinary canals is 
stripped as a whole from the membrana propria, and by 
the vis a tergo of the urine or of a fluid exudation is 
forced out of the tubule. These forms, which are made 
up of epithelial cells and have a lumen, we term epithe- 
lial tubular casts. With these, in the same sediment, 
we find cylinders made up of hyaline substance covered 
with epithelial cells. We may find the latter without 
the former. (PL VII., A, 5.) 

The epithelial cells appear cloudy, are somewhat 
swollen, and show very seldom a sharply defined sepa- 
rating border. Often their swelling has so far advanced 
that they appear more like a homogeneous finely granu- 
lated mass, in which the nuclei alone, separated from 
each other by regular distances, allow them to be recog- 
nized as epithelial cells. 

Among the epithelial cylinders there are some in 

which the coagulated interior bulges through the cover- 
10 



146 ANALYSIS OF THE URINE. 

ing of epithelium ; in others the central exudate projects 
at the ends. 

6. The uric-acid cylinders are distinguished by their 
characteristic composition, and they are only enumerated 
with the other on account of their form and place of ori- 
gin. The uric-acid cylinders occur in the urine of nurs- 
lings who suffer from uric-acid infarction of the kidney. 
As in the urine, so also in the wash of the child we 
observe small red forms, which under the microscope 
are recognized as cylinders, made up of small granules 
of the urates, and not, as their name would denote, of 
pure uric acid. They are brown-red, show distinctly a 
coarsely granulated structure, and vary greatly as to 
size. (PL VII., A, 6.) If treated with KOH, ammonia 
is set free and the cylinders disappear. Besides the 
perfect cylinders, we find fragments. 

7. Cylinders of bacteria and micrococci appear only 
with interstitial suppurative nephritis, and here also 
only in those cases where the disease is complicated 
with bacterian embolism of the urinary canals (nephritis 
parasitica, Klebs). We find these cylinders of the shape 
and size of the firm fibrine cylinders. They arise from 
the same place, the tubules of Bellini. We often find 
these forked, when they correspond to the junction of 
two straight tubes. They consist throughout of bac- 
teria and micrococci. Since the bacteria are in a state of 
rest, these cylinders resemble the coarse-grained granular 
cylinders ; these latter, however, are much smaller and 
more delicate. By applying a high power of the micro- 
scope, confusion is not easily possible. 



THE URINE. ' 147 

Under the above-mentioned forms the reader will 
miss some which have been described in other books, 
but which we ourselves have had no opportunity of 
observing ; and we conclude that, if such forms do occur, 
it is only very rarely. The cylinders of pus-cells must 
not be confounded with the short plugs of purulent 
matter which arise from the papillary part of the kid- 
ney and are characteristic of chronic pyelitis. Further, 
we mention cylinders of calcium oxalate and also cyl- 
inders with imbedded uric-acid crystals. It often hap- 
pens that to the cylinders crystals of uric acid and 
oxalate of calcium become attached. They do not ap- 
pear imbedded in the cylinder mass, but added after it 
has left the urinary tubules as an accidental attachment. 

6. Parasites. 

In the urine a number of parasitical growths may 
exist, some of which are of frequent occurrence, while 
others appear more accidentally. 

The most frequent forms which one has the oppor- 
tunity of observing are the following : 1. Bacteria ; 
2. Yeast fungi ; 3. Sarcinse ; 4. Oidium lactis ; 5. Dif- 
ferently developed spores and fragments of penicillium 
glaucum. Some forms occur oftener in alkaline and 
others in acid urine. 

1. Bacteria, predominantly inhabitants of alkaline 
urine, described by some authors as a low form of ani- 
mal life, by others as a plant, being spoken of synony- 
mously as Vibriones, Monades crepusculce, Microzymcz, 



148 ANALYSIS OF THE URINE. 

etc. At present it appears probable that they belong 
to the fungi and are grouped under Nageli's Scliyzomy- 
cetes. They are very different in their appearance, and 
from a practical standpoint, according to A. Vogel, they 
have received various names. It is only necessary to 
remember that they are fungi. 

A urine which contains an appreciable amount of 
bacteria appears always cloudy. After a long time part 
falls as a sediment to the bottom without the fluid be- 
coming clear. According to A. Vogel, the following 
forms are to be distinguished : 

a. The monad forms. These are round punctiform 
bacteria, which either remain quiet or show a quivering 
motion. One must exercise care not to confound with 
these the earthy phosphates which have a molecular 
movement. While the movement of a dead organism 
goes on in one place, the monad forms of bacteria 
change their position in the field. 

h. The rod forms. These are very small rods, 
scarcely the diameter of a blood-corpuscle, and im- 
measurable in thickness. Both ends are generally 
swollen and knob-formed. They are sometimes at rest 
and sometimes moving through the field. 

c. The vibriones. These are made up of the above- 
mentioned forms — two or more rod-like bacteria hanging 
on to one another, moving sometimes spirally and some- 
times with a motion resembling that of a fish's tail, 
going hither and thither with great rapidity. 

d. The hair forms, or chain forms. These are long, 
often reaching across the entire field, and are to be dis- 



THE URINE. • 149 

tinguished only by their length from the vibriones. 
Only with a very high magnifying power can their 
pointed composition be recognized. They move but 
seldom, and then very sluggishly, in the manner of a 
serpent. 

e. The zoogloa forms. These appear as masses of 
punctiform bacteria held together in a common gelatin- 
ous mass, resembling a precipitate of earthy phosphates 
held in mucus. 

All these forms may be observed in the same urine, 
and often under the same cover-glass. 

2. The yeast plants (Saccharomyces wrinw). — These 
are single vesicular cells, of the size of blood-corpuscles, 
and of somewhat oval shape. Usually, however, they 
are made up of small cells arranged like a rosary, some 
of the beads having two or three bud-like cells attached. 
(PL VIII., A, 1.) This fungus appears in much less 
quantity than the bacteria, and is found mostly in acid 
urine on a warm day. This plant has the greatest simi- 
larity to the yeast plant of beer (Saccharomyces cere- 
visice), without being identical. In diabetic urine this 
form occurs, but more vigorously developed. 

3. SarcincB. — This form has the greatest similarity 
to Sarcina ventriculi, but is appreciably smaller. They 
are arranged in groups of 2, 4, 8, etc., and the small 
cells are built up in cube form and present the ap- 
pearance of a cross-bound bale of goods. (PL VIII., 
A, 3.) 

The urine in which sarcinse are found is chiefly al- 
kaline, and in the sediment we find also calcium- and 



150 ANALYSIS OF THE URINE. 

triple phosphate. The evacuation of sarcinse lasts for 
weeks, sometimes for months. 

4. Oldium, lactis. — This appears in the form of long 
cells, recognized by their granules being arranged at 
regular intervals. These occur not infrequently in the 
fermenting urine of diabetes. 

5. Penicillium glaucum. — Besides the before-men- 
tioned fungi, there may exist in the urine also spores of 
this plant. In great part these exist as germs. Some- 
times they are covered with a coating of fine urates, 
appearing furry and brown-red, or the development is 
further advanced, and the branching forms become 
extended and make up a network of interlacing fibres. 
(PL VIII., A, 2.) 

The spores for the evolution of all the forms of fungi 
mentioned develop outside of the bladder. This rule, 
however, has exceptions. The sarcinse are always ex- 
creted with the urine from the bladder. Sometimes 
this may be the case with bacteria, though this may be 
explained from the use of unclean sounds or catheters. 
Cases have come to our knowledge, though very rarely, 
where there was certainty of no instrument having been 
introduced previously into the bladder or urethra. It is 
very difficult to ascertain whether these forms of fungi 
have any influence on the reaction or fermentation of the 
urine. The small chain fungus appears not alone in 
alkaline urine, but in every case in which an albuminous 
substance becomes fetid or decomposed. We therefore 
find the same in the secretions of different ulcers, in 
ichor, and in cholera stools. 



THE URINE. • 151 

In this place we may mention in passing an indica- 
tion which was formerly considered a characteristic sign 
of pregnancy. With the name kyesteine was christened 
that membrane which forms on the surface of long- 
standing urine, and which consists of an interlacing net- 
work in which calcium- and triple phosphates, bacteria, 
and sometimes also animal organisms, are imbedded. It 
forms, however, upon the urine of men, and has of late 
lost its significance. 

7. Spermatozoa. 

Spermatozoa appear with a strong power (Hartnack, 
III., 7 = X 330) as small rounded forms, with a longer 
or shorter hair-like tail. Seldom has one an opportunity 
of seeing them in motion in the urine. A urine which 
contains spermatozoa often shows white cloudy flakes, 
which under the microscope are resolved into a mass of 
spermatozoa imbedded in a finely granulated substance. 
Since spermatozoa are very light, they require several 
hours to settle. After six to twelve hours we find, 
besides the fiocculent lumps, also isolated seminal gran- 
ules. On account of the resisting capability of these 
structures, they may be found in the urine after several 
days. (PL VI., A, 3.) 

We find spermatozoa — t 

1. After coition, nocturnal pollution, etc., when a 
part of the semen remains behind in the urethra, and is 
washed out later by the urine. 

2. With spermatorrhoea. 

We also observe involuntary emissions in typhus. 



152 ANALYSIS OF THE URINE. 

In the urine of women we find spermatozoa after 
coition — a fact which may have great medico-legal im- 
portance. 

8. Cancer Elements. 

Two different forms of cancer elements are observed, 
though quite seldom : a. Isolated cancer-cells ; I. Pieces 
of cancer-tissue. 

a. The cancer -cells are variously (PL VIII., B, 1) 
and often quite oddly formed. They are large and for 
the most part caudate cells, with a very large and often 
more than one nucleus. Sometimes we observe the so- 
called vacuoles. Care must be taken not to regard the 
caudate cells of epithelium which come from the kidney- 
pelvis as cancer-cells. The cancer-cells correspond to 
the epithelial covering of a cancerous growth, and gen- 
erally arise in the bladder. Only from an abundant 
appearance of these peculiar and many-formed cells can 
we with certainty recognize a malignant growth. 

b. Fragments of villous cancer (PL VIII., B, 2) may 
occur in various forms in the urine sediment. We 
either find the same well preserved, when we are able 
to distinguish the papillary growth under the microscope 
(it seldom appears in this condition), or on the other 
hand it may be necrotic, when the diagnosis is attended 
with considerable difficulty. The well-preserved can- 
cerous tissue, under a magnifying power of 300 diame- 
ters, exhibits in its finest branches a characteristic tree- 
like formation, similar to fringe, which consists of a 
widened blood-vessel (Hohlkolben) covered with a 



THE URINE. ' 153 

single layer of epithelium. It is seldom that such a 
beautifully formed tree can be seen under the micro- 
scope. Usually sloughed off and much altered pieces of 
tissue only appear in the sediment, and the identification 
of these is very difficult. In the tree form the epithe- 
lium has generally undergone molecular disintegration, 
and is accompanied with bacteria; the villus itself is 
infiltrated with pus-corpuscles. In this molecular detri- 
tus, chiefly consisting of small flakes, we occasionally 
find forms which materially assist the diagnosis of vil- 
lous tumor. 

Often, if we treat the necrotic cancerous tissue with 
glycerine, and sometimes when we have not done this, 
we observe beautiful crystals of hsematoidine. They 
appear of a brown-yellow color, either in beautifully 
built small rhomboids or in small, yellow, grassy tufts. 
Such cancerous tissues, treated with fuming nitric acid 
under the microscope, show by the well-known rainbow 
play of colors the reaction of the biliary coloring mat- 
ters. Hsematoidine is recognized in old blood-extravasa- 
tions, but in the urinary sediment it is never observed 
except as isolated crystals. If, however, we find these 
crystals imbedded in necrotic tissue, then is the diagno- 
sis of old hemorrhagic and necrotic tissue assured. This 
condition has up to this time been found only with vil- 
lous tumors. Hsematoidine villus occurs only in acid 
urine. 

There is yet another sort of crystals which have also 
been observed by us only in necrotic villous tissue, 
which appear only in acid urine, and may also serve as 



154 ANALYSIS OF THE URINE. 

an index for the diagnosis. These are small, colorless, 
crossed, aggregated leafy crystals, in dnmb-bell form, 
which sometimes take on a spherical shape. These are 
a very rare form of calcium oxalate. 

Sometimes with a low magnifying power (120) we 
observe thicker and darker-colored, tube-shaped, branch- 
ing forms in necrotic flakes. These are small vessels 
which are to be seen in necrotic tissue. 

If the urine is strongly alkaline, we find the villous 
tissue so changed and incrusted with phosphates, that a 
diagnosis of it can scarcely be made. One investigation 
of the urine in these cases is hardly sufficient for a 
diagnosis. 

9. Entozoa. 

We have not up to this time had an opportunity of 
observing entozoa, or even fragments of them, in the 
urine. According to the claims of other authors, the 
hooks of echinococci occur. We have, however, observed 
single hooks, as also a fragment of the sac of the echino- 
coccus with the adhering animal forms, in the aspirated 
fluid of a kidney-tumor (PL VIII., A, 4) ; and it is pos- 
sible that by rupture of the same into the pelvis of the 
kidney the hooks might appear in the evacuated urine. 

In the tropics hematuria caused by entozoa is ob- 
served. Under this head the most important form of 
entozoa is the Distoma Immatobium or Billiarzia hcema- 
tobia. It penetrates most probably from the intestinal 
tract into the plexus venosus prostaticus, and there lays 
its eggs. These have an oval form, and on one end is 



THE URINE. 155 

to be seen a short point. They stop np the small ves- 
sels of the mucous membrane of the bladder ; then there 
arises a bladder-catarrh with haemorrhage, and the eggs 
become excreted in the urine. In the urinary sediment 
we find small flakes in such cases, in which under the 
microscope, besides numerous blood- and pus-corpuscles, 
are imbedded a great number of the eggs of BiTharzia 
hcematohia* 

It is hardly necessary to give a further description 
of accidental entozoa which have been found in the 
urine, but which have no especial significance. 

Bits of feather dusters, of wood fibre, of dried plant- 
tissue as tobacco leaf, dust, and cotton and woolen fibres 
are found in the urine. Besides this, it is hardly neces- 
sary to advise care as to cleanliness of the cover-glasses. 



EECAPITULATION. 

CONCEETIONS. 

By urinary concretions we understand the hard, 
stony formations, which are sometimes made up of nor- 
mal and at others of abnormal constituents. 

The size of these differs greatly. We find urinary 
concretions the size of the fist and larger, while some 
can only be recognized by the microscope. 

Every concrement, great or small, must allow the 
recognition of an arrangement of its molecules in layers, 

* We have to thank Dr. Sachs of Cairo for some very beautiful prepara-. 
tions of the natural sediment of endemic hematuria. 



156 ANALYSIS OF THE URINE. 

and have a more or less rounded form. A single excep- 
tion to this rule is the cystine stone, which upon cross- 
section shows a crystalline leafy formation rather than 
layers. 

If we wish to determine the nature of the urine con- 
cretions, we must employ the aid of a lens or micro- 
scope. 

Often we find such small concretions of uric acid 
that with the unaided eye they may often be mistaken 
for the crystals of uric acid (the rosette). Just so with 
small concretions of calcium carbonate, which show dis- 
tinctly their laminations with a lens of 100 to 200 diam- 
eters. 

The small concretions come usually from the kidneys, 
the larger from the bladder. 

The stones are formed either of one constituent or 
of different stone-forming elements arranged in layers 
(eccentrically). The uric-acid stones consist, as a gen- 
eral rule, entirely of uric acid or its salts ; the cystine 
stone only of cystine ; while the oxalates have generally 
a kernel of uric acid and an outer phosphatic layer. 
The phosphatic stones possess uric-acid centres. 

Whether these urinary concretions are formed of but 
one or several constituents can in every case be distin- 
guished. 

The best means of determining the constituents of 
the concretionary layers is to saw the stone in two 
halves with a bow or jeweler's saw. 

The innermost layer of the cut surface is the kernel ; 
this is from the size of a millet-seed to that of a pea or 



THE URINE. ' 157 

larger, and is contrasted better with the surrounding 
matter if the next layer is of another color. 

The kernel is the most important part of every stone. 
It alone explains to us the cause which has brought 
about the formation. If we find a uric-acid kernel in a 
phosphatic stone, we know that the primary condition 
which influenced the stone formation was due to uric 
acid. If the kernel happens to be a fragment of a bou- 
gie or a foreign body in the centre of a phosphatic 
stone, we must recognize the agency of the foreign body 
in producing the stone. 

From a practical or surgical standpoint, stones are 
classified according to their chief constituents. Thus 
we distinguish stones of urates, oxalates, phosphates, 
and cystine. This classification has a practical impor- 
tance which is not to be underestimated ; for if the sur- 
geon diagnoses a stone as phosphatic, he may conclude 
that it is a case for the lithotrite ; if formed of oxalates 
or urates, he may conclude that the stone is very hard. 

There are frequently stones which exhibit three or 
more stone-forming constituents in their layers. It is 
more convenient to 'classify such stones in two groups, 
according to the character of their kernels. The first 
group includes such stones as are formed by the sedi- 
ment of acid urine. The second group includes those 
stones the kernels of which are formed by foreign 
bodies, by blood-coagula, or from the constituents of 
alkaline urine. 

This classification conforms precisely to what we 
have designated as primary and secondary stone forma- 



158 ANALYSIS OF THE URINE. 

tion. The primary formation is the building of a kernel 
out of the sedimentary constituents of acid urine. The 
secondary formation is only an incrustation of a foreign 
body or of a kidney-stone arrested in the bladder. 

The primary stone formation occurs only in the kid- 
ney ; the secondary mostly in the bladder. 

A peculiar class is formed by the so-called " meta- 
morphosed " stones, which consist of earthy phosphates, 
and form a quite homogeneous and very porous mass. 
They are always the product of a chronic suppuration 
which has lasted many years ; the sediment of acid urine 
being dissolved by the alkaline pus, the earthy phos- 
phates are substituted. 

The primary stone formation is as a rule caused by 
uric acid, since bladder-stones for the most part have a 
kernel of that substance. 

In the investigation by Ultzmann of 545 bladder- 
stones, the kernels were found to be composed as fol- 
lows : 

Kernels of uric acid . . 441 = 80*92 per cent. 
" of calcium oxalate . 31 = 5*69 " 
" of earthy phosphates . 47 = 8*62 " 
" of cystine ... 8= 1*47 

Foreign bodies as kernels . . 18 = 3*3 

Analysis of the Concretions. 

Every large concretion must first be cut in two by 
means of a fine saw. The collected sawdust is well 
mixed, and should be investigated by the methods given 



THE URINE. ' 159 

below. By these methods we are enabled, by their 
characteristic reactions, to ascertain the principal con- 
stituent, and also to detect the various elements which 
compose the layers, but not to say in what order the 
layers occur. To find the arrangement of the layers, it 
is necessary to polish the smoothly sawed surface of the 
half, by rubbing for some time on a ground glass plate, 
when the different layers of the stone become distinctly 
visible. After dusting with a cloth, we may easily 
scrape as much powder from each layer by means of a 
pen-knife as will suffice for the test. In this way every 
urinary concretion may be accurately analyzed. Per- 
haps an example may be advantageously given. 

If a bladder-stone has been sawed in half, and by the 
analysis of the dust we have found that two thirds of 
the stone consists of incombustible (inorganic) and one 
third of combustible (organic) constituents ; and also if 
we have proved the presence of uric acid, oxalic acid, 
phosphoric acid, carbonic acid, calcium, magnesium, and 
ammonium ; furthermore, if we have polished the sawed 
surface of the stone, and recognize three distinctly sepa- 
rated and differently colored layers by means of the 
unaided eye, and find in the centre a kernel the size of a 
pea, which by analysis is found to consist only of uric 
acid, the dark-brown middle layer to consist only of cal- 
cium oxalate, and the outer white layer to be made up 
of the phosphates of calcium and magnesium, the com- 
plete analysis should be proceeded with as follows : 

Analysis, — Take several milligrammes of stone- 
powder and heat it carefully on a piece of platinum foil. 



160 ANALYSIS OF THE URINE, 

After intense heating, observe whether the powder is 
entirely consumed, or whether a residue remains ; fur- 
ther, whether the powder is consumed with a visible 
name, whether it decrepitates (oxalate of lime), or 
whether it gives off a characteristic odor. 

I. If the powder is entirely consumed by heat, the 
following stone constituents may be present : Uric acid, 
urates of sodium and ammonium, xanthine, proteine, and 
cystine. 

(1.) Proteine (fibrine) burns at a red heat with a 
brilliant yellow flame, and diffuses a strong odor of 
burning feathers or hair. 

(2.) Cystine burns with a weak bluish-white flame, 
and gives off a penetrating smell like burning fat and 
sulphur. The powder is dissolved in dilute ammonia, 
and shows under the microscope, upon evaporation of 
the same, beautiful hexagonal plates. 

(3.) Xanthine by the murexide test shows an orange- 
yellow color, and burns without a visible flame. 

(4.) Uric acid and sodium and ammonium urates 
burn without visible flame, and give with ammonia a 
beautiful red, and with KOH a beautiful violet mu- 
rexide. 

a. The urate of sodium is distinguished from the 
urate of ammonium, and from free uric acid, by the fact 
that on the foil upon which it has been heated there 
remains a light cloudiness. If a piece of red litmus 
paper is moistened with distilled water and laid upon 
this cloudy spot, a similar blue spot appears on the 
paper. This is caused by the sodium carbonate (or 



TEE URI2TE. 161 

caustic soda) which has been formed by heating the 
urate of sodium. The urate of ammonium and the free 
uric acid do not give this test. 

b. The urate of ammonium is distinguished from the 
free uric acid by the so-called cold ammonia test. This 
is accomplished as follows: Take a small test-glass, and 
to 0*1-0*2 gramme of the powder to be tested add a few 
drops of a concentrated solution of KOH. This glass is 
then covered by a watch-glass which has on the convex 
surface a small piece of wet red litmus paper ; if after 
a few minutes the paper becomes blue, ammonia is pres- 
ent. 

a Free uric acid gives naturally a negative result 
with the litmus test. 

II. If the powder is partially consumed, or is un- 
altered by heat, the stone consists essentially of calcium 
and magnesium salts. Then the following constituents 
may be present : Calcium oxalate, ammonium carbonate, 
calcium-magnesium and ammonio-magnesium phosphates. 

(1.) Calcium oxalate does not effervesce upon the 
addition of a drop of HC1. By intense heat this 
powder shows a peculiar glow and decrepitates slightly. 
The oxalate of calcium is by this means transformed into 
the carbonate of calcium ; and if now a drop of HC1 is 
added there ensues a brisk effervescence. 

(2.) Calcium carbonate effervesces upon addition of 
HC1 without first heating. (By this it is distinguished 
from the oxalate.) 

(3.) Calcium phosphates and the ammonio-magnesium 

phosphates do not effervesce upon the addition of a drop 
11 



162 ANALYSIS OF THE URINE. 

of HC1, either before or after incineration. (By this 
they are distinguished from the carbonate and oxalate.) 
The incinerated powder is readily soluble in HC1. If 
we add to this solution ammonium hydrate [(NH 4 )OH] 
drop by drop until the solution has become alkaline, 
there appears a white flocculent precipitate, which con- 
sists of the amorphous basic calcium phosphate and the 
crystalline ammonio-magnesium phosphate. Under the 
microscope the triple phosphates appear in stars or 
oblique crosses, while the calcium phosphate appears 
amorphous. Accordingly, from this precipitate we may 
conclude whether the calcium-magnesium or the am- 
monio-magnesium phosphate is predominant by the 
relative amounts of the amorphous and crystalline pre- 
cipitates. 



CHAPTER IV. 

REAGENTS AND APPARATUS FOR THE APPROXIMATIVE 
DETERMINATION OF THE CONSTITUENTS OF THE 
URINE. 

EEAGEXTS. 

Since the physician generally procures his reagents 
from the apothecary, for the sake of convenience we 
give the prescription formulae. For these reactions it is 
best to employ glass-stoppered bottles with wide necks, 
with a capacity of 250 c.c. 

A. Acids. 

1. Acid hydrochloric, concent., c. p., 200 grms. 

2. Acid sulphuric, concent., c. p., 200 grms. 

3. Acid nitric, concent., c. p., 200 grms. 
♦ 4. Acid acetic, concent., c. p., 200 grms. 

B. Bases and Salts. 

5. Potass, caust., p., alcohol dep., 100 grms. 
Aqua desi, 200 grms. 

6. Amnion., c. pur., liquid, 100 grms. 



164 ANALYSIS OF TEE URINE. 

7. Barii chloral cryst., 30 grins. 
Aqua dest., 200 grms. 
Acidi hydrochlor., 10 grins. 

8. Plumb, acet. cryst., 30 grms. 
Aqua dest., 200 grms. 

9. Cupri sulphat., 30 grms. 
Aqua dest., 200 grms. 

10. Magnes. sulphat., 



. aa 30 srrms. 
feal ammoniac, depurat., ) 

Aqua dest., 200 grms. 

Amnion, c. pur., liquid, 50 grms. 

11. Argent, nitrat., 5 grms. 
Aqua dest., 40 grms. 

For the latter reagents a pipette is advantageous. 

12. Ked and blue litmus paper in strips. 

Besides these necessary reagents, the following may 
be employed for special cases: Distilled water, ferric 
chloride, basic acetate of lead, mercuric nitrate, basic 
nitrate of bismuth (magist. bismuthi), fuming nitric acid, 
potassium nitrite, starch, chloroform, ether, alcohol, 
iodine in iodide of potassium solution, acetic acid, and 
sodium chloride. 

APPAKATUS. 

1. Six test-tubes, with rack. 

2. Ten wine-glasses or small test-glasses. 

3. Cylinder glasses of 100, 200, and 300 c.c. ca- 
pacity. 



REAGENTS AND APPARATUS. 165 

4. A graduated glass. 

5. A 100 c.c flask, with a glass tube through the 
cork. 

6. A wash-bottle for distilled water. 

7. A urinometer. 

8. A spirit lamp. 

9. Two small porcelain evaporating dishes. 

10. A ring stand with two rings. 

11. Filter paper. 

12. Four glass funnels for filtering. 

13. Glass rods. 

14. A microscope with appurtenances. 

15. A large beaker of 3,000 to 4,000 c.c. capacity. 

For special cases we must have watch-glasses, beaker- 
glasses, and pipettes ; and for quantitative examination, 
a delicate pair of scales. 



CHAPTER V. 

QUANTITATIVE DETERMINATION OF A FEW OF THE 
CONSTITUENTS OF THE URINE. 

As a first step toward the quantitative investigation, 
the entire mass of the excreted urine must be collected 
for a given time. Usually the amount for twenty-four 
hours is collected, but it must be observed that before a 
stool one should urinate, that none be lost by being 
mixed with the faeces. It is inadmissible to attempt to 
determine the amount for twenty-four hours from the 
quantity collected in one hour (p. 32). 

The urine should be collected in graduated cylinders. 
For large amounts one may graduate a vessel himself. 
Take a flask containing 1 litre of water at 15° C, 
and pour into the cylinder to be graduated, making a 
mark on the glass at the surface of the fluid, repeating 
this as often as necessary. 

If one desires to ascertain the mean amount of the 
urine excreted by an individual, the total amount should 
be collected for several days, and the quantity be di- 
vided by the number of days. 



QUANTITATIVE DETERMINATION. • 167 

I. ESTIMATION OF THE DEGKEE OF ACIDITY. 

In order to ascertain the degree of acidity of the 
urine, we add Na OH to the same until it reaches the 
point of neutralization, and then compute how much 
acid (we usually employ oxalic) is required to neutral- 
ize the quantity of sodium hydrate used. 

a. Volumetric Solution. 

We employ a one-tenth Na OH solution, which in 
1 c.c. contains 0*0031 grm. Na 2 0, which is sufficient to 
neutralize 0*0063 grm. of crystallized oxalic acid. If 
we employ normal sodium hydrate, we add 10 times its 
volume of distilled water. (Description of normal 
sodium hydrate, Mohr, " Titrirmethode," 4th edition, 
p. 83.) 

b. Example. 

We pour exactly 100 c.c. of urine into a beaker-glass, 
and add while stirring the sodium-hydrate solution drop 
by drop from a burette, until a drop of the urine on red 
litmus paper shows no blue and on blue litmus paper no 
red spot. The number of c.c. of Na OH added (say 14) 
we multiply by 0*0063, and the product (0*0882 grm.) 
shows the acidity of 100 c.c. of urine expressed in crys- 
tallized oxalic acid. 

II. ESTIMATION OF THE SOLID MATTEES. 

In order to estimate the solid matters, we take 10 c.c. 
of urine in a weighed porcelain dish, and evaporate on 



168 ANALYSIS OF THE URINE. 

a water-bath to dryness. It should then be kept for an 
hour in a drying chamber at 100°, and then allowed to 
cool in a desiccator. We now weigh and replace the 
dish in the drying chamber, weighing again at the ex- 
piration of an hour after cooling as before, repeating 
this until there is no variation in weight. The differ- 
ence of weight between the empty dish and that con- 
taining the solids is the weight of the solid matters in 
10 c.c. of the urine. Unfortunately, the result is always 
too small, for the action of the acid sodium phosphate 
on the urea at this temperature decomposes the latter, 
and ammonia and carbonic acid are driven off at the 
same time with the water. 

It is seldom that the physician employs this means 
for the investigation of the amount of solids, for by 
using Haser's or Trop's coefficients as satisfactory results 
are obtained, at least for him. (See p. 35.) 



m. ESTIMATION OF TJKEA. 

Liebig's Method, 
a. Reagents. 

1. Baryta solution. — One volume of a cold saturated 
solution of barium nitrate is mixed with two volumes 
of a cold saturated barium hydrate solution. 

2. Volumetric mercuric reagent. — This is a solution 
of mercuric nitrate (in which there must be no basic 
salt or mercurous compound), of such concentration that 
in 1,000 c.c. of the solution 71*48 grms. of pure mercury 



QUANTITATIVE DETERMINATION. • 169 

or 77*2 grms. of pure mercuric oxide (dried at 100°) are 
contained. (See Neubauer & Vogel, 1. a, 183 ; Mohr, 
1. c, 48, 1.) 

3. Sodium carbonate solution. — For Kaudenberg's 
modification we employ sodium-hydrogen carbonate. 

b. Method of Procedure. 

We take up 40 c.c. of urine in a pipette, and add 
20 c.c. of the baryta solution. Here, as in all other 
cases of quantitative work, the greatest care must be 
exercised. In the pipette there should be no foam, and 
one should read the division mark on the pipette which 
corresponds to the edge of the meniscus. We must be 
especially careful that none of the fluid be lost. If we 
have treated the urine with the baryta solution, the pre- 
cipitate of phosphates and sulphates which has sepa- 
rated should after some time be filtered off, using a dry 
filter-paper and allowing the fluid to run through into 
a dry beaker. The filtrate is therefore one third baryta 
solution and two thirds urine from which the sulphates 
and phosphates have been removed. We now take 
15 c.c. of this clear fluid by using a pipette, and allow 
it to flow into a dry glass vessel. This contains 10 c.c. 
of urine. Now, from a burette filled precisely to the 
zero point with the mercuric nitrate mixture, we add 
about as many cubic centimetres of the mixture as are 
denoted by the last two figures of the specific gravity of 
the urine (i.e., 15 c.c. if the specific gravity is 1*015), 
and try whether the limit has been reached. For this 



170 ANALYSIS OF THE URINE. 

purpose we place a drop of the well-stirred mixture by 
means of a clean glass rod on a glazed white porcelain 
plate, and in the centre of this drop add a small drop of 
a concentrated solution of sodium carbonate. If there 
occurs at the rim of contact of the fluids no rusty brown 
zone, we proceed to add more of the mercuric nitrate 
solution. If, however, even a faint rusty brown ring 
occurs, we know that the limit has been reached. 

The first effect of the addition of the mercuric 
nitrate is an exchange of bases with the alkaline 
chlorides present, forming Hg Cl 2 (corrosive sublimate) 
and an alkaline nitrate. The chlorides having been 
thus disposed of, the excess of mercuric nitrate com- 
bines with the urea, forming 2 CO H 4 N 3 , N 2 6 , 4HgO, 
which is a white precipitate. This precipitate dissolves 
to some extent in a slight excess of acid, from which it 
may be brought down white by rendering the solution 
neutral, on adding sodic carbonate. As soon, however, 
as the urea is all satisfied, a further addition of the mer- 
curic compound remains in the solution, and then gives 
a yellowish or brownish precipitate of basic mercury 
salt on neutralizing with the sodic carbonate, and the 
end of the reaction is indicated. Since the presence of 
chlorides deprives the mercuric nitrate of its power to 
precipitate the urea, the determination is inaccurate in 
so far as chlorides are present. For that reason the 
mercury solution is made a little stronger than the 
theory requires. If the urine contains 1 to 1^ per cent, 
of sodium chloride, 2 c.c. of the mercury solution must 
be subtracted from the amount used to give approxi- 



QUANTITATIVE DETERMINATION. 171 

mately accurate results, assuming that 15 c.c. of the 
urine is used.* The property which the chlorides pos- 
sess of destroying the precipitating power of mercuric 
nitrate upon the urea may be used to determine the 
amount of chlorides present, f 

When the mercuric-nitrate solution has been added 
in sufficient quantity, we allow the burette to stand for 
several minutes, and then read off how many cubic cen- 
timetres had been used. 

The reagent is so compounded that 1 c.c. of the solu- 
tion satisfies 10 milligrammes of urea. If we have em- 
ployed 20 c.c. of the reagent, then is 1 c.c. : 10 mil- 
ligr. : : 20 c.c. : x (= 200 milligr.). Consequently, if 
we have used 20 c.c. of the mercuric reagent, then must 
200 milligr. of urea have been present, which has en- 
tered into combination with the mercury. This was 
contained in the 15 c.c. of the urine and baryta mixture 
(which contained 10 c.c. of urine). We have therefore 
as a consequence : 

In 10 c.c. of urine are 200 milligr. of urea ; so in 
1,250 c.c. (the amount for twenty-four hours) we have 
10 : 200 : : 1250 : x ( = 25,000 milligr. — 25 grms.). 

1. Since the mercuric reagent is intended for a 2 per 
cent, urea solution, we only obtain exact results when 
to 15 c.c. of a 2 per cent, urea solution we add exactly 
30 c.c. of the reagent ; for 1 c.c. satisfies exactly 10 mil- 
ligr. of urea. 

Each c.c. of the reagent requires 72 milligr. of HgO, 

* Neubauer and Vogel, second edition, 1856, p. 106. 
t Neubauer and Vogel, p. 94. 



172 ANALYSIS OF THE URINE. 

according to the computation, in order to combine with 
10 milligr. of urea. In addition, however, a certain 
excess of HgO is necessary for the final reaction. Ac- ' 
cording to Liebig's calculations, this amounts per c.c. 
to 5*2 milligr. ; hence in 30 c.c. we have 30 X 5*2 = 
156 milligr. (excess of HgO). If we have added to 
15 c.c. of the 2 per cent, urea solution 30 c.c. of the 
volumetric reagent, then the mass of the mixture con- 
sists of 45 c.c, which contains 156 milligr. of excess of 
HgO ; that is to say, each c.c. contains 156 -j- 45 = 3*46 
milligr. Therefore for a distinct final reaction every c.c. 
of the mixture must contain 3*46 milligr. of HgO. 

If 15 c.c. of the urea solution contains 3*5 per cent, 
of urea, this would require 52*5 c.c. of the volumetric 
mercuric reagent. The mixture consists of 15 -f- 52*5 = 
67*5 c.c. In the 52*5 c.c. of the volumetric reagent are 
52*5 X 5*2 = 273 milligr. of excess of HgO ; hence in 
every c.c. there are 4*04 milligr. The final reaction 
occurs, however, with 3*46 milligr. In this case we have 
consequently 0*58 milligr. per c.c. too much free HgO. 
Therefore the final reaction would occur sooner. 

If, on the contrary, the solution contained but 1 per 
cent, of urea, we would have an error in the opposite 
direction. 

In order to eliminate both errors we proceed as fol- 
lows : 

(«.) If more than 30 c.c. of the volumetric reagent 
have been employed, before the sodium carbonate test 
we must add one half as many c.c. of water, as the ex- 
cess in c.c. of the volumetric mercuric reagent we have 



QUANTITATIVE DETERMINATION. ■ 173 

employed ; i.e., having used 52*5 c.c. of the reagent, we 
add 52 ' 5 ~ 80 = 11 c.c. of water to the mixture before the 
soda test. 

(h.) If less than 30 c.c. of the fluid have been em- 
ployed, for every 5 c.c. less than 30 we must deduct 0*1 
c.c. from the amount used. For example, we have used 
20 c.c. (10 c.c. less) ; consequently, we employ 20 — 0*2 
= 19*8 c.c. in the computation. 

2. If the urine contains from 1 to 1*5 per cent. Na CI, 
a greater quantity of the volumetric mercuric reagent 
is required. If without correction we estimate the 
urea, we find the quantity (15 to 25 milligr.) too great. 
In order to correct this error, we subtract 2 c.c. from 
the amount of the volumetric mercuric reagent used. 
For example, if we have employed 30 c.c. of the reagent, 
30 — 2 = 28 c.c. must be used in the computation of 
urea. 

If the absolute amount of urea alone concerns us, 
without considering it relatively, we must either preci- 
pitate the Na CI by means of a nitrate of silver solution 
or by Kautenberg's method. For this we take two 
samples of urine 15 c.c. each, and render one weakly 
acid with HN0 3 . We then drop in the volumetric mer- 
curic reagent until a permanent turbidity ensues. Then 
we note the number of c.c. we have employed, and then 
with the other sample make a determination of the 
amount of urea after Liebig's method. The mixture, 
however, must be made neutral by addition of freshly 
precipitated calcium carbonate. For the final reaction 
we employ, instead of the soda solution, sodium-hydro- 



174 ANALYSIS OF THE URINE. 

gen carbonate in water (see p. 169). From the number 
of c.c. we have employed in the last test we subtract the 
number used in first sample, and from their difference 
we estimate the urea. If in the first sample we used 1*5 
c.c. and in the second 31 c.c, we then employ in the de- 
termination 31 — 1*5 — 29*5 c.c. 

3. If albumen is present in the urine, a stoppered 
flask of 200 c.c. capacity should be employed, and the 
urine after the addition of a few drops of acetic acid 
should be heated until the albumen has separated in 
flakes from the clear urine. After closing the flask and 
allowing it to cool, the filtrate should be used in the 
usual manner. 

2. BunsewbS Method (Bunge). 

This is only applicable to urines free from, albumen 
and sugar. By it 50 c.c. of urine are treated with 25 
c.c. of a saturated ammoniacal barium-chloride solution, 
and filtered through a thick filter-paper ; then 15 c.c. of 
the mixture (containing 10 c.c. of urine) are poured into 
a thick- walled tube so that the sides are not sprinkled 
by the mixture. At the bottom of the closed tube have 
been placed about 3 grms. of crystallized chloride of 
barium. After the urine has been added, the tube 
should be sealed about three fingers above the fluid. 
The" tube is now placed in an oil-bath and heated for six 
hours at a temperature of 220° to 240°. After cooling, 
the point of the tube is broken off, and the resulting 
barium carbonate is placed upon a filter and carefully 
washed, then dissolved in a proper amount of HCL 



QUANTITATIVE DETERMINATION-. , 175 

Should some of the barium carbonate, after the washing 
of the tube with water, still adhere to the sides, it should 
be dissolved by a drop or two of HC1. The united solu- 
tions are then filtered, and the filtrate is precipitated 
with H 2 S0 4 . After some time the precipitated barium 
sulphate is collected on a filter, washed, heated to red- 
ness, and weighed. 

Since 233 grins, of barium sulphate correspond to 60 
grms. of urea, the weight of the urea may be estimated 
by a simple calculation. 

3. Knop-Hufner } s Method, 
a. Reagents. 

1. Knop's fluid (hypobromite of sodium). In 250 
c.c. of water 100 grms. of caustic soda are dissolved, and 
after cooling 25 c.c. of bromine are added. This should 
be freshly prepared. 

2. Cold saturated chloride of sodium solution. 

b. Mode of Procedure. 

The lower bulb and stopcock of Hufner's apparatus 
(the capacity having been accurately determined) are 
filled with a mixture of 10 c.c. of urine diluted with 
40 c.c. of water. The cock is then closed, no bubbles 
being allowed to remain. The second and larger bulb, 
connected by means of the stopcock with the lower 
bulb and opening above into the basin, is now washed 
with water and filled with Knop's fluid, diluted with an 



176 ANALYSIS OF THE URINE. 

equal volume of water. The basin is then sufficiently 
filled with the socliuni-chloride solution, and the eudi- 
ometer filled with water is inverted, the mouth below 
the surface of the sodium chloride solution in the basin, 
and placed over the narrowed neck of the second bulb, 
being retained in this position by the clamp above. 
The stopcock is then turned, and for a few minutes a 
violent evolution of gas is observed. After an hour the 
eudiometer may be withdrawn and the amount of the 
contained nitrogen estimated by Dumas's method. One 
gramme of urea furnishes 370 c.c. of nitrogen, at 0° C. 
and under 760 mm. pressure. 

IV. DETERMINATION OF URIC ACID. 

To 300 c.c. of urine are added 10 c.c. of HC1; the 
mixture is stirred briskly with a glass rod and allowed 
to stand forty-eight hours in a cool place. If the urine 
contains albumen, it should be removed by the method 
given on p. 174. If it contains sugar, 500 c.c. should be 
treated with mercuric acetate, and the precipitate washed 
upon the filter, then suspended in a little water and 
treated with hydrogen sulphide. The mercuric sul- 
phide is then washed with warm water, and the united 
wash-waters and filtrate treated with HC1. 

The separated uric-acid crystals should be collected 
on a weighed filter-paper which has been washed with 
HC1 and water and dried between two watch-glasses at 
a temperature of 100° C. 

By collecting the uric acid the work is essentially 



QUANTITATIVE DETERMINATION. ' 177 

lightened. The crystals lie mostly on the bottom of the 
glass ; a part, however, adhere to the walls, and a few of 
the smallest float on the surface. Since the uric-acid 
crystals have a high specific gravity, they precipitate 
very quickly (after one to two minutes). Those cling- 
ing on the side walls may be disturbed by means of 
a goose-feather clipped except at the end. The dis- 
engaged crystals settle very quickly, so that one may 
easily decant the clear fluid above into another cylinder, 
and bring the remaining fluid and the precipitate upon 
a small filter. Should any of the crystals go over with 
the decanted fluid, they quickly settle, and may be saved 
and brought upon the filter by decanting again. We 
decant in this way until no more crystals remain in the 
urine. If the crystals are very small, recourse must be 
had to filtration. 

The crystals are then washed with water until 
Ag N0 3 no longer renders the filtrate cloudy. It is a 
good precaution not to employ more than 30 c.c. of 
water; otherwise some of the uric acid will be dis- 
solved. If more than 30 c.c. is used, for each c.c. one 
must add 0*045 milligr. to the amount of uric acid deter- 
mined. 

When the uric acid has been washed, it should be 
dried for several hours between watch-glasses at 100° C, 
then cooled in a desiccator and weighed. 

The difference between the weight of the watch- 
glasses when empty and when containing the uric acid 
gives the weight of the urea contained in 300 c.c. of 
urine. 

12 



178 ANALYSIS OF THE URINE, 

Schwanert recommends as a correction, for every 
100 c.c. of urine, 0*0048 grm. to be added. 



V. DETERMINATION OF CREATrNTJSTE. 

a. Reagents. 

1. Chloride of zinc solution. Pure zinc oxide is dis- 
solved in pure HC1, and the solution evaporated on a 
water-bath (until no free HC1 is present) to a thick 
sirup. This is dissolved in strong alcohol, and the 
solution diluted until it has a specific gravity = 1*200. 

2. Milk of lime, which is stirred up before using. 

3. Diluted chloride of calcium solution. 

b. Mode of Procedwre. 

We render 200 c.c. of urine alkaline with milk of 
lime, and add diluted chloride of calcium solution as 
long as a precipitate forms. After two hours we filter 
and wash the residue, then quickly evaporate the wash- 
water and filtrate on a water-bath to a thick sirup. 
While it is yet warm, 50 c.c. of 95 per cent, alcohol are 
added to the mixture, and the same is transferred to a 
beaker-glass — washing the dish with a little alcohol — 
and allowed to stand for eight hours. Then the mix- 
ture is filtered through a small filter and the residue 
washed with more alcohol. The united filtrates are 
then evaporated down to 60 c.c. After cooling, \ c.c. 
of the above-mentioned chloride of zinc solution is 
added, and the mixture stirred briskly with a glass rod 
until turbidity occurs. It is then allowed to stand 



QUANTITATIVE DETERMINATION. ' 179 

forty-eight hours in a cool place. We now collect the 
separated creatinine chloride of zinc on a small filter, 
and weigh after washing (as by the described method 
for uric acid). In 100 parts of creatinine chloride of 
zinc are 62*44 parts of creatinine. 

VI. DETEKMINATION OF THE TOTAL AMOUNT OF NITEO- 

GEN. 

The chief amount of nitrogen in the urine is con- 
tained in the urea, and since, in Liebig's method for the 
separation of the same, other bodies containing nitrogen 
fall in connection with the urea, so in the greater num- 
ber of observations the amount of nitrogen present may 
be calculated approximatively from Liebig's determina- 
tion of urea. 

a. Reagents. 

1. Freshly calcined soda-lime. 

2. Normal sulphuric acid, which contains 40 grms. 
of anhydrous acid in every litre. Each c.c. corresponds 
to 0*014 grm. of nitrogen. (" Darstellung," Neubauer 
and Vogel, 1. c, p. 246 ; Mohr, 1. c, p. 74.) 

3. Sodium hydrate, which is an equivalent of the 
H 2 S0 4 ; i. e., 10 c.c. of the one must exactly neutralize 
10 c.c. of the other. 

4. Tincture of litmus. 

b. Mode of Procedure. 
Pour 20 c.c. of normal H 2 S0 4 carefully into a Var- 



180 ANALYSIS OF THE URINE. 

rentrapp and Wills' nitrogen bulb apparatus. In a 
strong flask of 100 c.c. capacity, containing a layer of 
soda-lime 2 c.c. thick, is poured 5 c.c. of urine, and the 
flask quickly closed with a double-perforated stopper 
and buried to the neck in a sand-bath. Through one of 
the perforations a tube leads to the nitrogen apparatus, 
and the other is supplied with a finely drawn-out sealed 
glass tube. The sand-bath is heated as long as bubbles 
pass through the nitrogen apparatus. When these cease 
the end of the glass tube is broken off, and all the am- 
monia is drawn from the flask by careful aspiration. 
Now pour the contents of the nitrogen apparatus into a 
beaker-glass, wash well with water, add a few drops of 
litmus tincture, and then add the sodium-hydrate solu- 
tion from a burette until the red color changes to 
blue. 

If no ammonia had been generated by the distillation 
of the urine, 20 c.c. of the sodium hydrate would have 
to be added to neutralize the 20 c.c. of H 2 S0 4 . If 14 
c.c. is however found to be sufficient, we know that 6 
c.c. of H 2 S0 4 have been satisfied by the ammonia formed. 
Since 1 c.c. of the acid corresponds to 0*014 grm. of 
nitrogen, then the total amount of nitrogen which has 
gone to form ammonia would be 6 + 0*014 = 0*084 grm. 
This would be given off by 5 c.c. of urine. Hence, if 
we had employed the whole amount of urine excreted 
in twenty-four hours (say 1,500 c.c), we would have the 
amount indicated in the proportion 5 : 0*084 : : 1,500 : x, 
= 25*2 grms. which is the total amount of nitrogen ex- 
creted in twenty-four hours. 



QUANTITATIVE DETERMINATION. . 181 

VET. DETERMINATION OF ALBUMEN. 

Pour into a beaker-glass 100 c.c. of filtered urine if a 
slight amount of albumen is present, or 50 c.c. if a mod- 
erate amount is present, or 20 c.c. if rich in albumen. 
In the second case add 50 c.c, and in the last 80 c.c. of 
water, and heat for half an hour on a water-bath. 
Should the albumen not have separated in large flakes, 
then one or two drops of acetic acid should be added 
and the heat again applied. As soon as the fluid has 
become clear it should be filtered through a small plaited 
filter-paper which has been previously weighed (see uric 
acid determination, page 176), taking care that all the 
coagula should be brought upon the filter, if necessary 
by the aid of a feather, and the beaker washed with hot 
water. Then the coagulated albumen should be washed 
into the point of the filter, and further washed with hot 
water until chlorides can no longer be detected in the 
filtrate by the AgN0 3 test. Then diy between watch- 
glasses at 100° until no loss of weight is observed. The 
determination of the total amount excreted in twenty- 
four hours is easily calculated from this. 

If one has a good polarizing apparatus, the amount 
of albumen may be easily determined, provided no 
sugar is present. 

Vin. DETERMINATION OF SUGAR. 

1. Fehling's Method, 
a. Volumetric Solution. 
Fehling's solution. In 1,000 c.c. there are 30*639 



182 ANALYSIS OF THE URINE. 

grms. of cupric sulphate, 173 grms. of pure crystalline 
tartrate of sodium and potassium, and 500 grms. of 
caustic soda solution of sp. gr. 142. (" Darstellung," 
Neubauer and Vogel, 1. c, 206.) Of this solution 10 c.c: 
are reduced by 0*05 grm. of sugar. 

b. Mode of Procedure. 

The determination depends upon the property that 
grape sugar possesses of reducing the cupric sulphate in 
the presence of an alkali. For this investigation a small 
amount of filtered urine is taken which has been largely 
diluted with water, unless it has previously been ascer- 
tained that only traces of sugar are present. Usually 
10 c.c. of urine and 190 c.c. of water are employed. A 
burette is filled with this mixture exactly to the zero 
mark. Then 10 c.c. of Fehling's solution are poured 
into a flask or porcelain dish and diluted with 40 c.c. of 
water, then heated over a flame, having previously pro- 
tected the flask with a piece of wire gauze. As soon 
as the copper solution begins to boil, the urine is added 
drop by drop from the burette. Soon the fluid becomes 
yellow, then red, and finally the last trace of the blue 
color disappears, and the red suboxide of copper rapidly 
subsides when the source of heat is removed. If allowed 
to stand for some time, the originally blue solution is 
seen to be colorless, or slightly yellow if more urine has 
been added than was necessary for the reduction of the 
copper. The entire loss of color of the fluid is conse- 
quently the limiting point of the reaction. 



QUANTITATIVE DETERMINATION. . 183 

Since with the unaided eye it is not easy to deter- 
mine when the fluid is colorless and inclined not to any 
tint whatsoever, it is advantageous to pass a few drops 
of the fluid through a small filter and divide the filtrate 
into two parts, one of which after acidifying with acetic 
acid is tested for copper with ferrocyanide of potassium, 
and the other with Fehling's solution for sugar. If by 
this method we obtain no reaction for either copper or 
sugar, neither is present in excess, and consequently the 
limiting point of the reaction has been reached. 

In the determination of the amount of sugar, the 
quantity of urine employed must be known. If 25 c.c. 
of the urine mixture were necessary to reduce 10 c.c. of 
Fehling's solution, the urine mixture being so made up 
that in 200 c.c. of it there were contained 10 c.c. of urine 
(the remainder water), then if x = amount of urine in 
25 c.c. of the urine mixture (the amount employed), we 
would have 200 : 10 : : 25 : x = 1*25 c.c. of urine. 

In this case 1*25 c.c. of the urine was necessary to 
reduce 10 c.c. of Fehling's solution. Now this solution 
is so constituted that for the complete reduction of 
10 c.c. of the same it is necessary to have 50 milligr. 
of sugar. Since, however, 1*25 c.c. of the urine has 
effected this reduction, it is certain that this quantity 
must have contained 50 milligr. of grape sugar. Hence 
it is easy to calculate the sugar in the entire amount for 
the twenty-four hours. 

If, for example, a diabetic patient had excreted 
5,000 c.c. of urine, we would have 1*25 c.c. : 50 milligr. 
: : 5,000 c.c. : x = 200,000 milligr., or 200 grms. of sugar. 



184 ANALYSIS OF THE URINE. 

If albumen is present, it must be separated before- 
hand in the usual manner. 

2. Knwpp>s Method, 
a. Volumetric Solution. 

Ten grms. of pure dried mercuric cyanide are dis- 
solved in some water; 100 c.c. of sodium hydrate (sp. 
gr. 1*145) are added, and the whole diluted to 1,000 c.c. ; 
40 c.c. of this solution are reduced by 100 milligr. of 
sugar. 

b. Mode of Procedure. 

Forty c.c. of the volumetric solution are heated in a 
beaker-glass, and urine added as in Fehling's method 
until the originally turbid mixture becomes clear and 
yellowish. From time to time a drop of this is thrown 
on a filter paper and touched with a rod dipped in am- 
monium sulphate. As soon as the spot no longer shows 
a brown edge, the reaction is complete. The method 
does not give quite as accurate results as Fehling's. 

The fermentation method is more complicated and 
unreliable than Fehling's. Very exact results are ob- 
tained by Soleil-Ventzke's saccharimeter or Wild's po- 
laristrobometer. 

IX. DETEKMESTATION OF CHLOKIKE. 

1. Mohr's Method. 

a. Reagents. 

1. Cold saturated solution of neutral chromate of 
potassium. 



QUANTITATIVE DETERMINATION. , 185 

2. Volumetric nitrate of silver solution, which con- 
tains in the litre 29*075 grms. of nitrate of silver (18*469 
grms. Ag), so that 1 c.c. of the same corresponds to 10 
milligr. of sodium chloride (= 6*065 milligr. chlorine). 
(Neubauer and Vogel, 1. c, 194.) 

3. Calcium carbonate, freshly prepared. 

b. Mode of Procedure. 

Ten c.c. of urine are poured into a platinum crucible, 
and 2 grms. of potassium nitrate free from chlorine are 
added, and the fluid evaporated on a water-bath to dry- 
ness. Heat the residue first gently, then intensely, over 
a Bunsen's burner, until the fused mass contains no car- 
bon (is white). The slag is dissolved in water and the 
dish carefully washed. Solution and wash-water are 
put in a beaker and treated carefully with a much 
diluted nitric acid, free from chlorine, until the fluid 
possesses a weakly acid reaction, which is again neutral- 
ized by freshly precipitated calcium carbonate. With- 
out regard to the sediment, three drops of the potassium- 
chromate solution are added, and the volumetric fluid 
then allowed to run in from a burette. As soon as the 
yellowish solution becomes reddish, it is a sign that 
all the chloride of sodium has been changed to silver 
chloride, and the formation of the red silver chromate 
begins. At this point the reaction is complete. 

If to 10 c.c. of urine employed 9*6 c.c. of the volu- 
metric solution has been added, since 1 c.c. of the same 
corresponds to 10 milligr. of Na CI, 9*6 c.c. shows 96 
milligr. of chloride of sodium. 



186 ANALYSIS OF THE URINE. 

If in 10 c.c. of urine 96 milligr. of Na CI are con- 
tained, then in the twenty-four hours' amount, i. e., 
1,400 c.c, we would have 10 : 96 : : 1,400 : x = 13*44 
grms., of Na CI in the amount for twenty-four hours. 

Should the patient have taken an iodine or bromine 
preparation previous to the investigation, this will 
quickly pass into the urine. In order to correct the 
disturbance from this cause, the solution of the slag is 
acidified with HN0 3 , and a few drops of a solution of 
potassium nitrite are added in order to make certain the 
separation of the iodine. It is then shaken up with 
carbon disulphide until this no longer takes up iodine 
(or bromine) ; the solution is then neutralized with 
sodium carbonate, evaporated, and treated as above. 
(Salkow T sH.) 

Falck's method is founded upon the precipitability 
of sulpho-cyanates, and the property of deprivation 
of color which AgNo 3 has over the red ferric sulpho- 
cyanate. 

X. DETEKMrNATION OF PHOSPHOEIC ACID. 

a. Reagents. 

1. Sodium-acetate solution : 100 grms. of acetate of 
sodium are dissolved in 900 c.c. of water, and to that 
solution 100 c.c. of acetic acid are added. 

2. Uranium nitrate solution, 1,000 c.c. of which 
must contain 20*3 grms. of pure uranic oxide: 1 c.c. 
corresponds to 5 milligr. of phosphoric acid. (Neu- 
bauer and Vogel, 1. c, 199.) 

3. Ferrocyanide of potassium solution. 



QUANTITATIVE DETERMINATION. 187 

b. Mode of Procedure. 

Fifty c.c. of tlie urine to be investigated are poured 
into a beaker-glass and 5 c.c. of the sodium-acetate solu- 
tion are added. This mixture is then warmed on a 
water-bath. When the urine is warm, the uranium 
solution is added drop by drop as long as a precipitate 
is observed. If this can not be recognized with cer- 
tainty, the mixture must be stirred up, a drop brought 
upon a porcelain plate, and a drop of a very dilute solu= 
tion of potassium ferrocyanide added. If a brownish- 
red color appears at the line of contact, the addition of 
the uranium solution must be discontinued, and the dish 
placed again on the water-bath until the mixture sim- 
mers. Then we try again whether the limit of the 
reaction has been reached ; usually this is not the case, 
so the uranium solution is dropped in until the end of 
the reaction is reached. The limit of the reaction occurs 
when all the phosphoric acid has been precipitated by 
the uranium solution. After this condition is reached, 
the next drop of the uranium solution, finding no phos- 
phoric acid, forms a brown precipitate with the ferro- 
cyanide of potassium. 

If we have used 13 c.c. of the uranium solution, 
then, since 1 c.c. of this satisfies 5 milligr. of phosphoric 
acid, we have the proportion, 1:5 :: 13 : x = 65 milligr. 
The 65 milligr. are contained in 50 c.c. of urine; hence 
for the entire phosphoric acid in the twenty-four hours' 
amount we have the proportion, 50: 65 ; : 1,300 :# = 
1,690 milligr., or 1.69 grrn. phosphoric acid. 



188 ANALYSIS OF THE UBINE. 

If we wish to determine the phosphoric acid in com- 
bination with the earths, 200 c.c. of urine are precipitated 
with ammonia and collected after twelve hours on a 
filter, and washed with ammonia water (1 part ammonia 
and 3 parts water). The filter is then broken at the 
point, and the precipitate washed down with a stream 
of water from a wash-bottle into a beaker-glass, and dis- 
solved while warm with as little as possible of acetic 
acid. Add 5 c.c. of sodium-acetate solution, diluted to 
50 c.c, and proceed as above. 

Of course the difference between the total amount 
of phosphoric acid and the amount in combination with 
the alkaline earths will be the quantity combined with 
the alkalies (K.Na and NH 4 ). 

XI. DETEKMINATION OF STJL^HUEIC ACID. 

One hundred c.c. of urine are heated with chloride 
of barium solution after acidification with HC1, and the 
precipitate of barium sulphate is brought upon a small 
filter-paper, the weight of whose ash is known, and 
washed until the filtrate gives no baryta reaction. Then 
the filter-paper and precipitate are incinerated in a plati- 
num crucible, moistened with a few drops of sulphuric 
acid, and again heated to redness. After cooling under 
a desiccator the mass is weighed. If the weight of the 
crucible and the ash of the filter is subtracted from the 
total weight, we have the weight of the barium sul- 
phate, from which the weight of the H 2 S0 4 may be 
easily calculated, since in 100 weighed parts of barium 



QUANTITATIVE DETERMINATION. ' 189 

sulphate are contained 34*33 parts of sulphuric acid 
(S0 3 ). 

The amount of sulphuric acid may be determined 
volumetrically, although this method is attended with 
much complication and is seldom employed. 

For the seldom used quantitative determination of 
the alkalies and alkali-earths, of indican, ammonia, biliary 
acids, and iodine, the works of Neubauer and Vogel, 
Hoppe-Seyler, etc., may be consulted. 



CHAPTER VI. 

KEY TO THE APPROXIMATIVE ANAIYSIS OF URINE. 

After the urine has been allowed to stand for an 
hour, its physical characteristics should first be observed. 

1. The twenty-four hours' amount. 

2. Color and transparency. 

3. Odor. 

4. Reaction upon litmus. 

5. Specific gravity. 

6. Quantity of the sediment. 

If a sediment has formed, the urine must be poured 
off and made use of for the several chemical tests. If 
the urine is quite cloudy, it should be filtered ; should 
it not then b# quite clear, it may be advantageous to 
warm it slightly to render it so. The sediment is set 
aside for analysis. 

CHEMICAL INVESTIGATION. 

A. Nitric Acid. 

Take about 15 c.c. of clear urine in a wine-glass, and 
pour down the side of the glass a sub-layer of pure 
nitric acid (HN0 3 ). "We find by this — 



KEY TO APPROXIMATIVE ANALYSIS. 191 

1. Albumen (p. 82) ; 

2. Urates (p. 56) ; 

3. Biliary coloring matters (p. 105); 

4. Indican (p. 61). 

If the urine contains much iodine, the zone between 
the fluids is colored a brilliant yellow-brown. The odor 
of iodine is perceived distinctly (p. 114). 

If but small amounts of these matters are present, 
they appear only after a few minutes. It is well to set 
the glass aside, while proceeding with the following test. 

B. Heat Test. 

Fill a test-tube one third full of clear urine, and heat 
over a spirit lamp. If a turbidity arises, then it contains 
either albumen or the earthy phosphates, which are preci- 
pitated by heat. Add now one or two drops of acetic 
acid : the earthy phosphates will be dissolved, but the 
albumen remains. Add now potassium hydrate in vol- 
ume equal to one half that of the urine in the tube : the 
albumen will go into solution, and the earthy phosphates 
will precipitate in small flakes. Heat the mixture again : 
if it becomes brown, sugar is present. If it does not 
become brown by boiling, set the tube aside in order to 
allow the phosphates to settle, that their amount and 
color may be noted. 

The earthy phosphates of normal urine are white. 
If they appear colored, the urine may contain various 
coloring matters / if blood-red or dichroic, blood-coloring 
matters are present. As a confirmation of this, albumen 



192 ANALYSIS OF TEE URINE. 

must be present, and the crystals of hsemine should be 
tested for in the sediment of the urine which forms 
naturally, micro-chemically, or from the albumen coagu- 
lum tinged by the coloring matters, by means of the 
same test (p. 102). Also under the microscope we 
almost always find blood-corpuscles in the urine sedi- 
ment. 

If the earthy phosphates appear rose-red, and there 
is no albumen present, plant-coloring matters are indi- 
cated (p. 100), especially after the internal use of 
rhubarb and senna. As a confirmatory test we add 
ammonia to the raw urine: a reddish color appears, 
which vanishes on addition of acid. 

If the earthy phosphates appear a dirty gray, usually 
uroerythrine (p. 99), the coloring matter of febrile urine, 
is present. To confirm this, there must be present a 
rose-red sedimentum lateritium, or upon addition of a 
few drops of acetate-of-lead solution a reddish or flesh- 
colored precipitate should fall. 

If the earthy phosphates appear brown, usually the 
biliary coloring matters are present. If the biliary col- 
oring matters are not decomposed, a beautiful iridescence 
may be obtained by Heller's test (p. 104). If no color- 
ation occurs, and also no green color is obtained (Ultz- 
mann's test), then decomposed biliary matters are pres- 
ent in the urine. By a relatively low specific gravity 
of the urine the H 2 S0 4 test is strengthened, and a mix- 
ture of the urine with potassium hydrate (KOH) ap- 
pears more darkly colored. 



KEY TO APPROXIMATIVE ANALYSIS. • 193 

C. Test for the Normal Coloring Matters of the Urine. 

1. Test with concentrated H 2 S0 4 (p. 62, Heller's 
urophseine test). 

2. Test for indican with concentrated HC1 and 
bleaching powder solution. (See p. 64.) 

D. Test for the Normal Inorganic Salts of the Urine. 

1. For chlorides: Take the wine-glass which has 
been used for the HN0 3 test A, and, if much albumen 
has not separated, stir up the mixture of urine and 
HN0 3 with a glass rod and add one or two drops of a 
solution of nitrate of silver (AgN0 8 ). (P. 69.) 

2. For alkaline phosphates, with the magnesium fluid 
mixture (p. 75), after precipitating the earthy phos- 
phates with KOH or NH 4 OH. 

3. For sulphates, with barium chloride (p. 77). 

F. Further Tests for Abnormal Matters. 

If it is necessary to test for the more obscure sub- 
stances which may be present, we use the afore- 
mentioned tests for ammonium carbonate (p. Ill), 
hydrogen sulphide (p. Ill), sodium carbonate (p. 113), 
and for leucine and tyrosine (p. 97). When the first 
three bodies are present, the urine is almost always 
alkaline. With the latter two, biliary matters are gen- 
erally present. 

F. Investigation of the Sediment. 

The color and consistence of the sediment should 
13 



194 ANALYSIS OF THE URINE, 

first be observed (whether crystalline, pulverulent, floc- 
culent, etc.), and also what is its chief constituent. 
We may do this either chemically or better micro- 
chemically and microscopically. (" Sediment e," pp. 
114-155.) Finally, we determine the visible organ- 
ized constituents of the sediment (epithelium cylinders, 
spermatozoa, etc.) by means of the microscope. 

If the urine has been investigated in accordance 
with this scheme, it is convenient, for the beginner 
especially, to write in a concise form all that he has 
found, in order that he may draw his conclusions from 
a glance at the analysis. 

This form may be conveniently made by simply 
folding a sheet of paper three times (see p. 195). 

The abbreviations are as follows : 



H 2 S0 4 test 


= Sulphuric-acid test for coloring matters 


Ind 


= Indican. 


+Ur 


= Urea. 


— Ur 


= Uric acid. 


CI 


= Chlorides. 


E. ph. 


— Earthy phosphates. 


A. ph. 


= Alkali phosphates. 


Sul. 


= Sulphates. 



In order to express whether the constituents are 
present in normal, increased, or diminished quantity, we 
employ the following : 

A normal amount present is denoted by n ; a mod- 
erate increase by m -f- ; & moderate decrease by m — ; 



KEY TO APPROXIMATIVE ANALYSIS. • 195 

a large increase by st -f- (strongly increased) ; a large 
decrease by st — (strongly decreased). 

The results may be arranged as follows : 



Physical Characteristics. 



Normal Substances. 

H 2 S0 4 test . CI . 

Ind " . E. ph. 

+Ur. . . . A. ph. 

— Ur .... . Sul. . 



Abnormal Matters in Solution. 



Sediment. 



Conclusion. 



The increase and decrease is that of the percentage. 
Such a filled out table appears as the following ex- 
ample. 



196 ANALYSIS OF THE URINE. 



Physical Chaeacteeistics. 

24-hour amount = 4,000 c.c. 
Pale yellow, somewhat turbid, acid. 
Sp. gr. = 1*040. Slight sediment. 



NoEMAL MATTEES. 

H 2 S0 4 test . . st — CI .... m 

Ind m + E. ph. . . st 

+ Ur l m- A -PVl . st 



Ur Sul. 



Abnoemal Matters in Solution. 
Sugar in considerable quantity. 



Sediment. 
Consists of mucus in normal quantity. 
Microscopically, isolated yeast fungi are seen. 



'Eesult = Diabetes mellitus. 



With such a blank one may write in its proper 
division the result of each test that he has applied from 
A to F, the presence and amount of the substances 
found, and the conclusion he may have drawn. If we 
look ajb the table in the example, we conclude: 1st. 
From the 24-hour amount, that there exists polyuria ; 
2d. From the specific gravity, concerning the quantity 



KEY TO APPROXIMATIVE ANALYSIS. ' 197 

of solid matters, diabetes / 3d. From the pale color and 
the lack of urates, that no febrile condition exists ; 4th. 
Finally, from the amount of sugar present, diabetes mel- 
litus. 



CHAPTER VII 

GENERAL DIAGNOSIS. 

At the time when the entire investigation of the 
urine consisted in observing the physical characteristics, 
and then only with preconceived notions, so that one 
took pains to torture the " urine signs " to conformity 
with a system previously constructed on a speculative 
basis, the investigation of the urine could afford no 
essential service in the diagnosis of febrile processes, and 
not seldom afforded a cloak to ignorance and charlatanry. 

It is only since the advance of organic chemistry and 
the use of the microscope, and since the connection be- 
tween the characteristics of the urine and the tissue 
metamorphosis on the one hand, and the construction of 
the urinary apparatus on the other, has been clearly 
understood, that the investigation of the urine has dared 
to claim for itself an important character and a scientific 
value. At present no one doubts that it is essentially 
necessary for the diagnosis of disease. Moreover, in 
certain cases, from the urinary analysis alone can their 
nature, condition, and intensity be determined. It would 
be a gross error to believe that from the urine all possi- 



GENERAL DIAGNOSIS. • 199 

ble diseases can be diagnosed ; but it would be equally 
unjust to attempt to exclude as useless urinary investi- 
gation. 

Before we speak of the diagnosis of diseases of the 
urinary apparatus, we will mention what is important 
uroscopically with the various diseases in general. In 
this series we comprise those indications which are most 
valuable and necessary to the practicing physician. 

1. Take the twenty-four hours' amount, and consider 
if it be normal, increased, or diminished. The normal 
amount is generally 1,500 c.c. If the twenty-four hours' 
amount is considerably increased, we have to do with 
polyuria ; if it is diminished considerably, with oligu- 
ria ; and, if there is no urine excreted, with anuria. 

Polyuria may be either physiological or pathological. 
In the first case it is urina potus or urina spastica ; in 
the latter case, on the other hand, we have either hyd)*u- 
ria or diabetes. In order to make a differential diaomo- 
sis, we must calculate from the specific gravity the 
amount of solid matters excreted in twenty-four hours, 
by means of Trap's or of Haeser's coefficients (p. 35). 
If the quantity of solid matter is normal (nearly 70 
grammes) or thereabout, it is a case of urina potus / i. e., 
as far as its solid constituents are concerned, a normal 
urine diluted with much water. If the amount of solids 
is diminished, we have a Jiydruria to treat, which may 
occur with several cachexies. If, on the contrary } the 
solids are considerably increased, we have a diabetes. If 
with the diabetes a large amount of sugar is present, we 
have a diabetes mellitus. If, on the contraiy, no sugar is 



200 ANALYSIS OF THE URINE. 

present, we have a diabetes insipidus (by an increase of 
the nitrogenous materials, an azoturid). 

Oliguria is easy to diagnose, and occurs chiefly with 
febrile processes. The urine is generally dark-colored 
and strongly concentrated. In the latter stages of kid- 
ney diseases, after the appearance of uraemia, the amount 
constantly decreases. A slight oliguria may occur tem- 
porarily after a loss of water, as by profuse sweating or 
diarrhoea. 

Anuria with an unobstructed urethra occurs only in 
severe kidney affections, in connection with uraemia. 
Besides, this occurs with stricture, stone, and new 
growths, as so-called retention of the urine. 

If the amount of urine has been satisfactorily inves- 
tigated, we observe : 

2. Whether or no the specimen is a febrile urine. 
We may also often determine whether the febrile pro- 
cess is acute or chronic, since the acute inflammatory 
processes are usually accompanied by important febrile 
indications. 

Febrile urine has generally a dark reddish-yellow 
color, is concentrated, and its volume likewise dimin- 
ished. If, as is seldom the case, the amount of urine is 
not diminished, but on the contrary is increased, the 
coloring matters are likewise increased. We regularly 
find in fever urine a distinct layer of urates by the 
HN0 3 test (A). 

If an acute exudation process is present at the same 
time, the urine is concentrated, acid, and contains many 
urates, which come down upon cooling, colored by a red 



GENERAL DIAGNOSIS. ' 201 

coloring matter (uroerythrine) as a rose- or tile-red sedi- 
mentum lateritium. At the same time the excretion of 
the urea, sulphates, and alkali phosphates is increased^ 
while the chlorides are diminished. With an increase 
of the disease the chlorides may steadily diminish, until 
they finally disappear at the climax. 

In the stage of resorption the concentration of the 
urine gradually disappears, the reaction becomes gradu- 
ally neutral or alkaline (from carbonate of ammonia), 
the chlorides are again present in normal amount, and 
in the sediment are found urates (as urate of ammo- 
nium) and earthy phosphates. Simultaneously the urine 
may be normal in volume or somewhat increased, while 
during the exudation process it was diminished. 

Although in most cases it is not very difficult to 
diagnose from the urine an acute inflammation or a so- 
called status f ebrilis, we are not able to make (except- 
ing the diseases of the urinaiy apparatus) a differential 
diagnosis between the various forms of febrile affections. 
Even in the kidney diseases one may be so far deceived 
that, being misled by the uroscopic indications, he may 
mistake an accompanying aif ection for the principal dis- 
ease. For example, the urine of scarlatina is analyzed, 
and one finds a febrile state in connection with a de- 
squamative or parenchymatous nephritis. From the 
uroscopical indications we diagnose acute nephritis, al- 
though scarlatina and not nephritis is the predominant 
disease. The former could not be diagnosed from the 
urine. 

Notwithstanding that the differential diagnosis of 



202 ANALYSIS OF THE URINE. 

febrile affections is not possible, the analysis of the urine 
should not be omitted, since from it we may often deter- 
mine an advance or improvement in the condition, and 
often detect further complications. For example, the 
reappearance of the chlorides is regarded as a favorable 
sign, while the appearance of albumen is an unfavorable 
symptom. 

Among the acute febrile processes there are a few to 
be mentioned which lend characteristic peculiarities to 
the urine, and which are of essential importance to the 
physician to confirm his diagnosis. 

With icterus we constantly find biliary matters in 
the urine. 

With icterus levis, an icterus of a lighter grade, sim- 
ply a febrile state is discovered (i. e., much urates in an 
acid, dark, concentrated urine), and a rich mass of biliary 
coloring matters, the chlorides at times appearing in less 
quantity. With icterus gravis — in which the principal 
cause is not simply a resorption of the biliary constitu- 
ents, from a catarrhal affection of the ductus choledochus 
and cysticus, but much more a parenchymatous affection 
of the liver itself, often also a quick breaking down of 
the liver cells — besides a large quantity of the urates 
and biliary coloring matters, we find also albumen, and 
at the same time small amounts of the biliary acids. 
The chlorides are entirely wanting. 

With acute liver atrophy we usually find a urine rich 
in biliary coloring matter, of low specific gravity and 
acid reaction. The urea is greatly diminished, and in 
its place we find leucine and tyrosine (the latter also as 



GENERAL DIAGNOSIS. ' 203 

a sediment). The chlorides have entirely disappeared. 
Moreover, urates and albumen, the latter in great amount, 
are present. Biliary acids can be proved in such urine. 
In the sediment is found a great amount of epithelial 
casts and fibrinous cylinders, besides kidney epithelium 
and isolated blood-corpuscles. 

With acute lung diseases we find a larger amount of 
urates corresponding to the insufficiency of respiration. 

With heart diseases, or irregularities of the circula- 
tion, we find a stasis in the venous system and resulting 
albuminuria (renal stasis) ; just as there occurs with 
many acute febrile diseases, and especially exanthemata, 
a kidney affection as a complication. 

With peritonitis we find usually a large amount of 
indican. (Senator.) 

The urine of meningitis is generally very strongly 
concentrated, corresponding to the slowness of the pulse. 
Since the differential diagnosis between meningitis and 
typhus is very difficult, and clinically often impossible, 
various indications may be gathered from the urine. 
Unfortunately, they are not to be entirely depended 
upon. The urine of meningitis should show a high 
specific gravity and a w^eakly acid reaction, and should 
contain some albumen and much urates. Besides the 
increase of the specific gravity, another characteristic 
should be that, by boiling the native urine, the earthy 
phosphates should separate (Heller's bone earths). The 
chlorides are not strongly diminished. In typhus, on 
the contrary, the specific gravity is not so high, and the 
urine is acid and should contain no so-called bone earths. 



204 ANALYSIS OF THE URINE. 

The chlorides should almost always be greatly dimin- 
ished. Urates are present, and albumen may be found 
in larger amount. At the same time in typhus urine a 
large amount of carbonate of ammonium should be 
proved, the urine at the same time possessing a distinct- 
ly acid reaction. 

With meningitis spinalis one should find besides 
these constituents much indican. The specific gravity 
of this urine, in contradistinction to that of meningitis 
cerehraliSy should be lower. 

With acute articular rheumatism we observe, besides 
a high specific gravity, an acid reaction, increased urea 
and urates, and a characteristic strong increase of earthy 
phosphates. The sediment should contain beautiful 
rose-red urates and oxalate of calcium, colored by uroery- 
thrine. If pericarditis exists also, the chlorides and 
earthy phosphates diminish rapidly, but the uroerythrine 
appears still more beautiful. 

If the urine is not colored dark reddish-yellow, and 
urates are not present in large amount, we may deter- 
mine that no febrile process accompanies the disease. 
Among the f everless and consequently for the most part 
chronic affections, several possess certain characteristic 
peculiarities in the urine, which for completeness we 
mention. 

Chlorosis furnishes a very pale and light urine, cor- 
responding to the lessened tissue-metamorphosis in the 
organism. With hysteria a similar urine appears, but 
with an increase at times in mass, and a larger amount 
of indican (urina spastica). The urine of hudruria and 



GENERAL DIAGNOSIS. , 205 

diabetes is also pale. How these two may be distin- 
guished from one another has been already explained. 
With diabetes rnellitus the specific gravity is higher in 
spite of the increased amount. An increase of indican 
is observed by the reaction, and in the later stages of 
this disease much albumen appears. The remaining 
normal constituents are diminished in percentage, but 
the absolute amount (with the exception of uric acid) is 
increased. In saccharine urine very many and beautiful 
yeast plants are found in the sediment, as well as net- 
works of penicillium. 

With chronic diseases of the spinal cord often occurs 
a pale and light urine, which besides much indican and 
bone earths contains a very small quantity of sugar (?). 
In the sediment Heller claims to have often observed 
sarcinse. 

With rachitis, and especially with osteomalacia, the 
earthy phosphates are strongly increased, so that they 
form a copious sediment. 

With diseases of the bone, especially if a great part 
of the skeleton is involved, we find an increase of car- 
bonate as well as oxalate of lime in the sediment, to- 
gether with the so-called bone earths, partly in solution 
and partly in the sediment. 

With chronic articulcvr rheumatism is found a 
strongly acid, concentrated urine, which contains a 
sediment rich in urates and calcium oxalate. A great 
increase of earthy phosphates is characteristic. 

In gout we find a similar urine, except that the uric 
acid is excreted in less amount, and is therefore retained 



206 ANALYSIS OF THE URINE. 

in the organism. At times a beautifully crystallized 
sediment of free uric acid is found. 

In intermittent fever, in the cold stage, the excretion 
of urine is increased, and it is light and clear, while in 
the hot stage it is dark and saturated. 

In chronic liver affections, in spite of the fact that 
no fever exists, we find a dark, acid, concentrated urine. 
Undecomposed biliary coloring matters are seldom pres- 
ent ; the normal coloring matters are strongly increased 
(decided H 2 S0 4 , and indican reaction) ; and generally 
uroerythrine is also present. This increase of the color- 
ing matters of the urine is accounted for by an increased 
exchange and excretion of biliary coloring matters. 
The earthy phosphates are usually diminished. In the 
sediment we find frequently urates colored rose-red by 
uroerythrine, and many times a small amount of calcium 
oxalate. 

In chronic skin diseases, especially in those affections 
which destroy in part the function of perspiration, we 
find regularly a kidney disease as a complication ; i. e., 
pemphigus, etc. 

With scurvy and purpura hemorrhagica we fre- 
quently find haemorrhage from the kidneys ; as also in 
melanwmia, with which we usually have parenchyma- 
tous kidney affections. 

With leucaemia the urine is rich in uric acid, and 
often also hippuric and lactic acids occur. 



CHAPTER VIIL 

DIAGNOSIS OF THE DISEASES OF THE URINARY 
APPARATUS 

If urine which contains neither pus nor blood, nor 
has been accidentally mixed with albuminous fluids, 
shows the albumen reaction, this condition is called true 
albuminuria ; and disease of the kidney itself is indi- 
cated. If, on the contrary, albumen is present only as 
blood or pus, the condition is called false albuminuria, 
and is usually a symptom of an affection of the kidney- 
pelvis, ureters, or bladder. Mixed albuminuria is when 
there is more albumen in the urine than can be ac- 
counted for by the presence of blood and pus. 

Whether, in addition to the amount contained in 
blood and pus, albumen in other forms is present in the 
urine, can only be accurately determined by one very 
familiar with the albumen reaction, and sometimes even 
he will find it quite difficult. The best way of learning 
to distinguish false from mixed albuminuria is to add to 
normal urine the so-called healthy pus of a suppurating 
wound, and, after allowing the sediment to form, apply 
the test for albumen. 



208 ANALYSIS OF TEE URINE. 

MICROSCOPICAL AND CHEMICAL AIDS TOE DIAGNOSIS OF 
THE DIFFERENT FORMS OF ALBUMINURIA. 

A. True Albuminuria. 
1. Hypercemia of the Kidney. 

From the active congestion caused by unusual im- 
bibition, no albumen is found in the urine. The daily 
amount of urine is increased, its color becomes pale yel- 
low or may be clear as water, the specific gravity is very 
low, and the normal solid constituents are usually ex- 
creted in greater quantity. 

Albumen in small quantity is present in urine when 
for a considerable time the kidneys have been obliged 
to perform their function excessively, as for example in 
diabetes mellitus or insipidus. It also appears in small 
quantity (one tenth per cent., and generally even less) 
from hyperemia of the Mdney, caused by various irri- 
tating substances which are excreted by the same ; for 
instance, after the long-continued internal use of balsam 
copaivse, turpentine, cubebs, corrosive sublimate, and 
other acrid or astringent remedies. 

A change in the chemical constitution of the urine 
should also be mentioned as a cause of irritation ; that 
is, hyperemia of the Mdney. It is well known that a 
concentrated, strongly acid urine may give rise to mani- 
fold disorders of this organ, and may sometimes even 
cause a slight albuminuria, which is, however, generally 
transitory. 

Partly from chemical and partly from mechanical 



DISEASES OF THE URINARY APPARATUS. 209 

irritation, as by oxaluria and excessive amount of uric 
acid in the urine, especially if this fluid has a strongly 
acid reaction and the uric-acid crystals are pointed or 
jagged, a mild albuminuria may be produced. This can 
however be easily cured, if one pays attention to the 
character of the urine, and induces the patient to drink 
a great amount of water ; for by this means the solids 
of the urine, especially the alkali-salts, are excreted in 
greater quantity, which, besides neutralizing the acidity 
of the urine, are excellent solvents of the uric and oxalic- 
acid crystals. 

The crystals of uric acid, in addition to their irri- 
tative action, not infrequently become kernels for the 
formation of renal calculi. 

Further, a slight temporary albuminuria is observed 
after convulsions, epileptic and intermittent fever pa- 
roxysms, and various other forms of vascular contrac- 
tion. It also frequently occurs in conjunction with 
acute fevers (Bartels' febrile albuminuria), especially 
with acute exanthemata, and finally sometimes with 
inflammatory affections of the skin, as anthrax, furun- 
culosis, erysipelas, burns, etc. Often by hyperemia of 
the kidney, if the primary disease advances, a parenchy- 
matous inflammation is introduced. 

From passive hyperemia of the kidney, a result of 
general venous sluggishness, the albuminuria increases 
or diminishes in proportion to the more or less complete 
venous stasis. 

Often a retardation of the renal circulation results 

from feebleness of the heart's action. If, however, in 
14 



210 ANALYSIS OF THE URINE. 

such cases the normal blood-pressure is restored by 
proper medicines, the albuminuria usually disappears. 
The renal circulation is also impaired by chronic pul- 
monary diseases, especially emphysema, and by all tu- 
mors and exudations which retard the general current of 
the venous blood; as, for example, large pleuritic effu- 
sions, ascites, ovarian cysts, and advanced pregnancy. 
Puerperal eclampsia is not alone accompanied by a tran- 
sitory renal venous stasis (Rosenstein), but very fre- 
quently also by parenchymatous nephritis (Bart els). 

As a consequence of marasmus and with various 
cachexies, a hypersemic condition of the kidney is ob- 
served. 

The characteristics of simple hyperemia of the kid- 
ney are that the specific gravity of the urine is generally 
though not always high, the solid constituents are pres- 
ent in diminished or else in normal quantity, and the 
reaction is acid. Albumen appears in small quantity 
(one tenth per cent, or even less). In the sediment 
either no organized elements are found, or at most single 
blood-corpuscles and epithelial cells from the straight 
tubules ; hyaline casts are scarcely ever seen. 

In febrile albuminuria, in addition to this, the quan- 
tity of the urates is increased, while that of the chlorides 
is greatly diminished. 

In stasis of the renal circulation proper, the twenty- 
four hours' amount of the urine is always diminished, 
the specific gravity is high, the color dark, and the reac- 
tion acid. This urine contains a large amount of urates, 
which frequently render it turbid, and settle down as a 



DISEASES OF TEE URINARY APPARATUS 211 

copious sediment. About one fifth per cent, or more of 
albumen is present. In the sediment are usually found 
hyaline casts and single cells of kidney epithelium. 

This renal stasis is distinguished from parenchyma- 
tous nephritis by the absence of cellular forms (blood- 
and lymph-corpuscles, granular epithelium from the 
kidney) and of granular casts in the sediment of the 
urine. 

The urine accompanying renal stasis is distinguished 
from that of chronic interstitial nephritis (cirrhosis of 
the kidney), and that of the "waxy" kidney, by its 
dark color, its high specific gravity, its small amount 
during the twenty-four hours, and the abundance of 
its urates. 

2. Parenchymatous Nephritis. 

Two forms of parenchymatous nephritis are ac- 
cepted — acute and chronic. The acute form usually 
occurs as a sequence of other acute diseases, and is sel- 
dom primary ; while the chronic, the so-called second 
stage of Blight's disease, is generally primary, and sel- 
dom follows the acute form. 

a. Acute Parenchymatous Nephritis. 

Of acute parenchymatous nephritis two forms are to 
be recognized. One is a slight affection, the so-called 
catarrh of the urinary tubules, or desquamative ne- 
phritis ; the other a more severe form, the acute paren- 
chymatous nephritis proper (diffuse or croupous), the 
so-called acute Bright's disease. 



212 ANALYSIS OF THE URINE. 

Acute parenchymatous nephritis in most cases allows 
a favorable prognosis. Only in those cases where there 
is a complete suppression of the urinary secretion 
(anuria) is there usually a fatal termination. De- 
squamative nephritis always runs a favorable course. 

a. Catarrh of the urina/ry tubules, or desquamative 
nephritis. — This form preferably affects the straight 
tubules. It lasts from eight to fourteen days, but often 
a still shorter time. Fever is not an essential character- 
istic. Those affected complain of stiffness in their 
joints, pain in the region of the sacrum, and general 
lassitude. They frequently walk about during the 
whole course of the disease. (Edema seldom occurs. 

The urine shows the following characteristics : 

The twenty-four hours' amount is either normal or 
slightly diminished; the same is true of its specific 
gravity. The color is wine-yellow, seldom a dirty yel- 
low ; the reaction is acid. The fluid is always rendered 
turbid by the presence of cellular bodies, and sometimes 
deposits a thick sediment. 

The normal constituents are excreted in normal pro- 
portion. 

Of abnormal substances, albumen is found in mod- 
erate quantity, one tenth to one fifth per cent., and some- 
times traces of blood-coloring matter. 

The sediment consists chiefly of an increased amount 
of mucous secretion. Microscopically are seen numerous 
epithelial cells from the straight tubules, which are 
sometimes colored brown by the coloring matter of the 
blood. They are frequently connected together in the 



DISEASES OF THE URINARY APPARATUS. 213 

form of hollow cylinders, being known as epithelial 
casts ; or the epithelial cells may form the covering of a 
hyaline cylinder (both together forming the epithelial 
cylinders). (PL VII., A., 5.) In addition are found 
isolated hyaline cylinders, red blood-corpuscles, and a 
somewhat larger number of lymph-corpuscles. 

Inflammation of the straight tubules also results from 
the introduction of instruments after catheterization of a 
sensitive bladder, dilatation of strictures, introduction 
of the lithotrite, etc. It also accompanies acute inflam- 
matory processes, especially the exanthemata. 

Ms contigruo, desquamative nephritis arises from 
inflammation of the bladder caused by the retention of 
urine after gonorrhoea. 

The higher degree of this affection is — 

/5. Acute parenchymatous nephritis proper. — This 
disease may occur with very severe disturbances, and 
also without noteworthy subjective symptoms. The 
latter condition is observed in reduced cachectic indi- 
viduals. 

The important symptom, which first causes the pa- 
tient as well as the physician alarm, is dropsy. This 
appears especially characteristic as oedema of the face, 
which produces a bloated appearance. Severe cases are 
accompanied by anuria and convulsions. The less the 
twenty-four hours' amount of urine, so much the more 
severe generally becomes the disease ; so that with an 
anuria of long duration the disease usually proves fatal. 

The urine shows the following changes : 

The twenty-four hours' amount is greatly diminished, 



214 ANALYSIS OF TEE URINE. 

often to 250 c.c. The specific gravity is usually in- 
creased ; the reaction is acid, and the urine has a brown- 
yellow, dirty color, being quite turbid from the presence 
of many cell elements. The latter after long standing 
settle as a considerable sediment. 

The normal constituents are excreted in diminished 
amount. 

Of the abnormal matters, we find serum-albumen in 
great amount, and at times blood-coloring matters also 
in considerable quantity. Albumen comes in from 1 to 
5 or 6 per cent., so that the urine is transformed by boil- 
ing to a thick jelly. 

The sediment is generally colored brownish, and 
consists principally of a thick mass, often colored brown 
by blood-coloring matters, at times of long corkscrew- 
twisted fibrine-cylinders, containing often a great amount 
of lymph- or red blood-corpuscles (blood-cylinders) or 
adhering brown-colored (hemorrhagic) epithelium of 
the urinary canals. In other cases we find only cell 
remnants surrounding distinctly visible nuclei, which 
are in part contained within and in part on the surface 
of the cylinder. Besides, many isolated epithelial cells 
from the tubules are found, together with many blood- 
and lymph-corpuscles, and a mass of molecular detritus, 
richly colored brown from the blood-coloring matters. 

Acute parenchymatous nephritis either develops it- 
self primarily, or it occurs as a consequence of another 
acute disease. It appears especially frequent after acute 
exanthematous affections, namely, after scarlatina, and 
as a consequence of diphtheritis, f ebris recurrens, phleg- 



DISEASES OF THE URINARY APPARATUS. , 215 

mon, erysipelas and carbuncle, after employment of 
preparations of which cantharides may be taken as the 
type, and also after the internal exhibition of violent 
and caustically acting medicaments, as corrosive sub- 
limate. 

It is frequently observed after taking cold, and after 
burns of wide extent on the skin. After articular rheu- 
matism, in cholera, and in pregnancy it appears fre- 
quently as a complication. 

Finally, acute nephritis occurs frequently in the 
course of chronic parenchymatous nephritis. 

Although the prognosis in most cases of this disease, 
even if it has lasted several weeks or months, is favor- 
able, yet in single severe cases, with the appearance of 
acute uraemia, the fatal end may come in a few days. 
On the other hand, the acute form may pass over to the 
chronic. 

I). Chronic Parenchymatous Nephritis. 

The first symptom of this disease is also dropsy. 
Fever is not present. 

The urine shows the following changes : 

As long as chronic nephritis advances, or while the 
disease remains at its height, the twenty-four hours' 
amount is diminished ; but as soon as the chronic nephri- 
tis retrogrades, the amount of urine increases, and in the 
stage of the so-called kidney atrophy it may pass beyond 
the normal amount. 

The color of the urine is dirty yellow, often brown- 



216 ANALYSIS OF THE URINE. 

yellow. It is turbid from numerous cell forms, which 
after settling show a macroscopically visible sediment. 
The reaction is acid, and the specific gravity is usually 
lowered. 

The normal constituents (especially urea) are ex- 
creted in diminished quantity. 

Of the abnormal substances, albumen is found from 
one half to one or two per cent. Blood-coloring matters 
are present ; at least, traces are provable. 

In the sediment we find at times in large amount, 
but usually isolated, dark nucleated granular cylinders, 
or half granulated, made up of a hyaline ground-sub- 
stance with insulated granular masses sparingly dis- 
tributed over its surface. (PI. VII., A, 2.) There are 
also found nucleated granular kidney epithelium and 
single blood- and lymph-corpuscles, with molecular de- 
tritus. 

In the condition of secondary atrophy the twenty-four 
hours' amount is considerably increased. The specific 
gravity is much lowered. The color is pale yellow. 
The urine is also turbid, and shows a macroscopically 
visible sediment. 

The excretion of the normal constituents, especially 
the urea, when the atrophy affects both kidneys, is 
greatly diminished. 

Albumen is present in only small amount (one tenth 
to one fifth per cent.). 

In the sediment we find granular masses consisting 
of detritus, granular kidney epithelium, and isolated 
fragments of granular cylinders. 



DISEASES OF THE URINARY APPARATUS. 217 

This disease occurs in a minority of cases as a 
sequence of the acute nephritis, but generally it has 
other modes of origin. 

Chronic parenchymatous nephritis arises from the 
acute parenchymatous nephritis, though most frequently 
after scarlatina, after severe rheumatic processes, after 
profuse bone suppuration, and also from the nephritis of 
pregnancy. 

Parenchymatous nephritis originates in the chronic 
form after purulent osseous and articular inflammations 
in consequence of intractable syphilis, pulmonary phthi- 
sis, malaria, scrophulosis, and other cachexies ; also from 
the immoderate use of spirituous liquors, which is of 
especial importance. 

The prognosis is not very favorable. There are 
indeed cases in which, after years of a dropsical and 
albuminurious condition, recovery has taken place, 
though this termination is not the usual one. After 
syphilis and malaria we may by energetic treatment 
secure healing, and also after a profuse osseous suppura- 
tion, when the contained pus has been gotten rid of sur- 
gically. 

3. Interstitial Nephritis. 

The interstitial connective tissue of the kidney may 
be altered either by hyperplastic growth or by destruc- 
tive suppuration. Accordingly we distinguish two 
forms of this disease, the hyperplastic interstitial ne- 
phritis and the suppurative interstitial nephritis. 



218 ANALYSIS OF THE URINE. 

a. Hyperplastic Interstitial Nephritis — Cirrhosis of the 
Kidney— Genuine Kidney Atrophy. 

This affection occurs most frequently in advanced 
life, very seldom in youth. 

Cirrhosis may have existed for a long time, and may 
have attained a high grade, without the patient having 
by any symptom whatever suspected any disease of the 
kidney. Dropsy occurs not at all, or only in the last 
stages. 

A tense and quick pulse and a hypertrophy of the 
left ventricle are the usual symptoms of this form of 
disease of the kidneys. 

Disturbances of vision complicate especially this 
form of the kidney diseases, and are not seldom 
the first symptom for which the physician is sum- 
moned. 

The urine shows the following conditions : 

The external appearance after excretion is- similar to 
that of normal urine. It is bright and clear, and shows 
sometimes a darker, sometimes a lighter color, corre- 
sponding to its concentration. The twenty-four hours' 
amount is generally increased, though polyuria is not 
always the rule. The specific gravity is either normal 
or more frequently lowered. The reaction is acid. 

The normal constituents are usually excreted in 
normal mass. 

Of the abnormal constituents, albumen is found in 
moderate amount (0*1, 0*2, 0*5 per cent.). It may also 
entirely disappear from the urine. This happens espe- 






DISEASES OF THE URINARY APPARATUS. 219 

cially in a condition of perfect rest; hence more is 
found in the day than in the night nrine. 

Macroscopically we do not observe a sediment after 
long standing. Usually we find nothing abnormal by 
our macroscopic investigation. Only at times, when 
after long standing we pour off all but the last drop of 
the urine, and then examine this thoroughly by the 
microscope, we find a hyaline cylinder, a blood-cor- 
puscle, or a little changed kidney epithelium. 

The prognosis of this disease, if the diagnosis is cor- 
rect, is an unfavorable one, though the course of the 
disease may be long. 

The aetiology is obscure. 

b. Suppurative Interstitial Nephritis. 

This may be of traumatic, idiopathic, pysemic, or 
metastatic origin. It often proceeds from chronic 
pyelitis, when the disease of the pelvis extends to the 
connective tissue of the kidney and sets up suppuration. 
It is this usually which, after surgical interference with 
the urinary organs, closes the scene. Suppurative 
nephritis occurs in this way, after catheterization of a 
paralyzed bladder, after forcible dilatation of strictures, 
and after lithotrity. It was on this account that this 
disease was formerly known as surgical kidney. 

Kidney calculi predispose especially to suppurative 
nephritis, and that complicated with great kidney ab- 
scesses and pyonephrosis. 

The urine shows the following conditions : 



220 ANALYSIS OF THE URINE. 

It has a dirty yellow color, is cloudy, and is passed 
in small quantity. The odor is putrid. The specific 
gravity is diminished, the reaction being usually neutral 
or alkaline. 

The normal constituents, especially urea, are ex- 
creted in diminished quantity. 

Of the abnormal constituents, albumen is present in 
greater mass (J to 1 per cent.). Blood-coloring matters 
are usually present. Not seldom carbonate of ammo- 
nium and ammonium-sulphide are present in greater 
quantity. 

The sediment is considerable, and consists chiefly of 
flocculent pus mixed with blood in greater or smaller 
amount. Microscopically are found, besides numerous 
bacteria, molecular detritus and kidney epithelium, and 
not seldom beautifully formed, thick, often-branched 
cylinders, which are formed of bacteria (pyelo-nephritis 
parasitica, Klebs). If it is complicated with parenchy- 
matous nephritis, we find also dark, granulated, mostly 
thick cylinders from the straight tubules. 

The course is usually acute, and the process generally 
ends fatally. In chronic cases the large abscesses dis- 
charge into the pelvis of the kidney. 

We can only diagnose kidney abscesses by estimat- 
ing the amount of pus excreted per diem, which we can 
easily do with graduated cylinders. A suddenly ap- 
pearing and then disappearing amount of pus in the 
urine, together with microscopical evidences of broken- 
down kidney-tissue (glomeruli, tubules, etc.), furnish the 
best points for the diagnosis. 



DISEASES OF THE URINARY APPARATUS. ■ 221 

4. Amyloid Kidney. 

Amyloid degeneration of the kidney is generally a 
local manifestation of a constitutional disease. It occurs 
therefore frequently in connection with extended osseous 
suppuration, as well also as with other long continuing 
and profuse suppurations. With pyonephrosis on one 
side, not seldom the other kidney becomes amyloid. 
Scrophulosis, chronic tuberculosis, and obstinate syphilis, 
and at times also malarial cachexy, favor especially amy- 
loid degeneration of the kidney. In rare cases this 
affection is due simply to disturbance of nutrition. Fre- 
quently it is complicated with parenchymatous nephritis. 

The amyloid disease of the kidney is developed quite 
insidiously and without marked symptoms, though as a 
rule the amyloid kidney excretes a larger amount of 
urine in twenty-four hours than the healthy kidney in 
the same space of time. This excess is never so great, 
however, as is usually found in general atrophy of the 
kidney. 

The urine shows the following conditions : 

It is pale yellow, clear, and has a low specific gravity 
and acid reaction, and deposits no visible macroscopic 
sediment. 

The normal constituents are generally excreted in 
diminished amount. 

Of the abnormal matters, serum-albumen is present 
in moderate quantity (from 0*1 to 1-2 per cent.). Be- 
sides serum-albumen, we often find globuline in rela- 
tively considerable mass (Senator, Edlefsen), which may 



222 ANALYSIS OF TEE URINE. 

be regarded in such cases as characteristic of this dis- 
ease. 

In the sediment, seldom visible macroscopically, are 
found generally no cell-elements, but sometimes narrow 
hyaline, or also broader waxy, glistening, fragile, yellow- 
colored cylinders. (PL VII., A, 4.) Occasionally we 
observe brightly glistening, amyloid, degenerated kidney 
epithelium, which, in the same manner as the waxy 
cylinder, is colored reddish brown by a watery solution 
of iodine, and further upon addition of sulphuric acid a 
dirty violet color. Blood does not appear in the sedi- 
ment with pure amyloid kidney. 

The prognosis depends upon the constitutional dis- 
ease. If one has to do with syphilis and malaria, favor- 
able response to treatment may be expected. 

In the differential diagnosis of the various forms of 
albuminuria, the following points are to be observed : 

1. If already in the urine a macroscopically visible 
sediment is present, consisting of a great mass of cell- 
elements (blood-corpuscles, pus-corpuscles, cylinders, 
etc.), we have to do either with parenchymatous or sup- 
purative insterstitial nephritis. 

a. In parenchymatous nephritis we find in the sedi- 
ment epithelial, fibrinous, and granular cylinders, kidney 
epithelium, and blood- and lymph-corpuscles. 

b. In suppurative interstitial nephritis we find in 
the sediment blood- and pus-corpuscles, much bacteria, 
and sometimes also bacterian cylinders, or short and 
thick darkly nucleated granular cylinders. 



DISEASES OF TEE URINARY APPARATUS. 223 

2. If the urine is clear or only clouded by urates, 
and no sediment is discovered which consists of a con- 
siderable mass of cell-elements, then we have to do with 
renal stasis, or with a hyperplastic interstitial nephritis, 
or with an amyloid kidney. 

a, Henal stasis is distinguished from both the other 
diseases of the kidney by a decrease in the twenty-four 
hours' amount of urine, by its dark color and high speci- 
fic gravity, and often by the abundance of urates. The 
amyloid kidney and the hyperplastic interstitial nephri- 
tis are characterized by an increase of the amount of 
urine ; also in both diseases the urine is bright and 
clear, of pale yellow color and low specific grav- 
ity. 

b. Amyloid kidney differs from interstitial nephritis 
in that the urine contains globuline, and by the presence 
of waxy cylinders and amyloid degenerated kidney epi- 
thelium. 

Clinically we very constantly find with amyloid kid- 
ney (as with parenchymatous nephritis) dropsy, while 
with genuine atrophy this occurs seldom, and if at all in 
the latter stages. 

In genuine kidney atrophy is found constantly hy- 
pertrophy of the heart and a quickened pulse, while 
these do not occur in parenchymatous nephritis and 
with amyloid kidney. 

Finally, with amyloid kidney usually there is an 
enlargement (amyloid degeneration) of the liver and 
the spleen. 



224 ANALYSIS OF THE URINE. 

B. Forms of Mixed Albuminuria, 

Mixed albuminuria is recognized from the fact that 
there is more albumen present than corresponds to the 
amount of pus in the sediment. It includes those dis- 
eases of the kidney -pelvis which in advanced stages in- 
volve the kidney-structure, and thereby complicate the 
pyorrhoea with true albuminuria. 

The kidney-pelvis is limited toward the kidney by 
the calices and the papillae renales. It is therefore easy 
to understand how with extended inflammation of the 
kidney-pelvis the neighboring papillary part may be- 
come involved. A proof that the papillary part of the 
kidney has become involved by the pyelitic process, is 
the presence of kidney-epithelium in the sediment. One 
also finds in long-continued suppurative processes in the 
pelvis of the kidney, that the same is enlarged at the 
expense of the papillary part, the latter being more or 
less consumed. 

1. Pyelitis. 

Pyelitis is often a local manifestation of an acute 
febrile process ; it not infrequently accompanies paren- 
chymatous nephritis and (in advanced stages) diabetes 
mellitus. The use of copaiva balsam, cubebs, and simi- 
lar powerful medicaments, sometimes has this disease 
as a consequence. Kidney-stones, parasites, new growths, 
and tuberculosis of the kidney -pelvis are almost always 
accompanied by suppurative pyelitis. From contiguity, 
either this or pyelo-nephritis is developed by the dam- 
ming back of the urine in prostatic hypertrophy, para- 



DISEASES OF THE URINARY APPARATUS. 225 

lysis of the bladder, stricture of the urethra, etc., pro- 
vided at the same time a purulent bladder-catarrh is 
present. Pyelitis also frequently arises from compres- 
sion of the ureters by tumors, large exudations, or a 
retroflected or pregnant uterus. Finally, it may occur 
also after maltreatment of gonorrhoea, or mechanical 
injuries to the neck of the bladder and the bladder 
proper with surgical instruments, etc. 

We may distinguish an acute and a chronic pyelitis. 
Not infrequently the sediment of the urine furnishes 
means for the diagnosis of pyelitis calculosa and tuber- 
culosa. 

The constitutional diseases which bring about pye- 
litis crouposa and diphtheritica are so severe in them- 
selves that they obscure the symptoms of the pyelitis. 

a. Acute pyelitis. 

The clearest form of acute pyelitis occurs after sur- 
gical interference with the urinary organs, in the course 
of acute inflammatory processes, and after improper 
treatment of gonorrhoea. 

The twenty-four hours' amount is diminished ; the 
urine is dark-colored and turbid, and has a high specific 
gravity and an acid reaction. After standing, a distinct- 
ly visible precipitate appears. 

The excretion of normal matters is not essentially 
changed ; it shows in a high degree the peculiar char- 
acteristics of a febrile process (the urates considerable, 

the chlorides diminished). 
15 



226 ANALYSIS OF THE URINE. 

Of the abnormal constituents, albumen occurs always 
in far greater amount than corresponds to the slight pus 
sediment. The percentage of the albumen varies from 
0*1 to 0*5 and thereabouts. Blood-coloring matters are 
in small amount, and not constantly present. 

The sediment consists chiefly of an increased (cloudy) 
mucous secretion, mixed with pus in less or greater 
amount. Microscopically, we find pus-corpuscles of 
round, spherical form, and often many adhere together, 
forming a cylindrical plug. These cylindrical plugs 
arise from the papillae renales, and contain not seldom 
beautiful kidney-epithelium. We always find blood- 
corpuscles, but at times only singly. The epithelium of 
the papillary part of the kidney appears in great amount 
in oval or pear-shaped forms. Often two or three 
epithelial cells hang together. We also find at times, 
though seldom, these epithelial cells colored reddish 
brown by the blood-coloring matters, which with the 
colorless pus-cells and the yellow blood-corpuscles make 
up a beautiful picture under the microscope. 

The so-called single and double caudate epithelium, 
with tile-form 'arrangement, which is generally desig- 
nated as pelvis-epithelium, is not a characteristic of pye- 
litis. The epithelium of the kidney-pelvis does not 
differ essentially from the epithelium of the bladder, 
which appears also in the urinary sediment of pyelitis ; 
and on this account only the epithelium of the papil- 
lary part is a characteristic for the diagnosis of pye- 
litis. 

With acute pyelitis kidney-epithelium occurs in 



DISEASES OF THE URINARY APPARATUS. 227 

greater amount, often ten pieces in the field, while with 
chronic pyelitis it appears very sparingly, 

Acute pyelitis, if it occurs in consequence of surgical 
interference in the bladder, or following acute inflam- 
matory processes, or with gonorrhoea, allows of a favor- 
able prognosis, since in the course of a few weeks heal- 
ing is apt to occur. Sometimes, however, there arises 
from the acute form — 



b. Chronic Pyelitis. 

In chronic pyelitis the twenty-four hours' amount of 
urine is increased. For this reason polyuria may be re- 
garded as a characteristic symptom. In severe cases, not 
infrequently 5 to 6 litres are evacuated in the twenty- 
four hours. The color of the whey-turbid urine is pale 
straw-yellow, and has at times a peculiar tendency 
toward greenish-yellow. The specific gravity is always 
low and the reaction acid. The sediment is more or 
less copious, corresponding to the amount of pus. 

The absolute amount of normal constituents is not 
essentially changed, but their percentage appears to be 
diminished on account of the polyuria. 

Of the abnormal constituents, albumen appears con- 
stantly in greater amount than corresponds to the con- 
tained purulent sediment. The mass of albumen is 
generally 0*1 to 0*5 per cent. Blood-coloring matters 
are usually not present. 

The sediment has a greenish-yellow color, is floccu- 
lent, consists chiefly of pus, and does not stick to the 



228 ANALYSIS OF THE URINE. 

glass. The pus-corpuscles with long-continued pyelitis 
are often branched or have tooth-like projections, unlike 
the pus-corpuscles of other cicute purulent catarrhs of 
the urinary passages. They also form, since they are 
pressed together in greater mass, roundish, oval, or even 
long plugs (purulent plugs of the ductus papillares), 
which are characteristic of chronic pyelitis. (PL VII., 
B, 2 and 3.) . 

Epithelial cells are very sparingly present in chronic 
pyelitis ; and if the suppuration is very severe, they 
may be entirely wanting, since they apparently by endo- 
genous cell-formation break up into pus-corpuscles. 

Blood-corpuscles do not occur with the common 
chronic pyelitis. With pyelitis in consequence of renal 
calculi, tuberculosis, new growths, and entozoa in the 
kidney, they are, however, of constant occurrence. 

Chronic pyelitis only seldom admits of a favorable 
prognosis. In our latitudes it is usually complicated 
with primary or even (in consequence of suppuration) 
secondary stone-formation. Not infrequently it passes 
over into pyonephrosis, later perinephritis, with final 
discharge of the purulent contents toward the outer sur- 
face of the body, less often into the bladder or intestines. 
This happens usually in young or strong individuals. 
In weak or old patients chronic pyelitis passes over into 
interstitial suppurative nephritis, and chronic uraemia 
closes the scene. 

c. Pyelitis Calculosa. 
Calculosis renalis is chiefly introduced by a deposit 



DISEASES OF THE URINARY APPARATUS. 229 

of uric acid within the kidney or the kidney-pelvis. 
Therefore the spontaneously arising kidney concretions, 
for the most part, are composed of uric acid or its salts, 
and have a yellowish-brown color. In addition, renal 
calculi may be introduced by excretion of cystine (most 
infrequent), and by excretion of earthy phosphates, as 
the so-called secondary stone-formation in the kidney- 
pelvis, in consequence of haemorrhage and long-continued 
suppuration. Oxalate of calcium only very rarely is 
the primary cause of stone-building; it plays its part 
later in the layer formation. 

The most frequent cause of the formation of kidney- 
stone, as we have before mentioned, is the excretion of 
crystalline uric acid within the kidney, in consequence 
of its absolute or relative (through concentration of the 
urine) excess. Naturally the concentration and the in- 
creased acidity thereby produced furnish favorable con- 
ditions for the formation of the characteristic rough or 
pointed crystals of uric acid, which are almost constantly 
the foundation of kidney-stones (Ultzmann, " Ueber 
Harnsteinbildung," in "Wiener Klinik," 1875, No. 5). 
Therefore the indications of kidney-stone must be looked 
for in a concentrated, acid urine, rich in uric acid, espe- 
cially if the same is excreted in jagged or pointed 
forms. 

The beginning of kidney-calculi can be diagnosed if, 
in connection with the above-mentioned conditions of 
the urine, a light albuminuria (hyperaeinic condition of 
the kidney) is observed, and a few blood-corpuscles 
appear in the sediment. 



230 ANALYSIS OF THE URINE. 

The accompanying albuminuria is only temporary, 
and appears especially only with a considerable concen- 
tration of the urine or with a great excess of uric 
acid. 

The presence of large concretions in the kidney may 
be diagnosed from the occurrence of a parenchymatous 
haemorrhage. The urine- from the before described 
chemical constitution shows, especially after violent bod- 
ily exercise, a red-brown or coffee-colored tinge. 

If the concretions do not disappear after such a 
strong kidney-hseinorrhage, there arises gradually a pye- 
litis — the pyelitis calculosa. This may occur in two 
forms, a light and a severe. 

The light form occurs generally with kidney-concre- 
tions of small size, and characteristic indications are 
often offered by the sediment ; while the more severe 
purulent form differs from the ordinary pyelitis chronica, 
in that we constantly find blood-corpuscles in the sedi- 
ment. The latter form of pyelitis calculosa occurs gen- 
erally with greater concretions, and affords later a ter- 
mination for pyonephrosis and paranephritis with dis- 
charge of purulent matter. 

The lighter form of pyelitis calculosa shows the fol- 
lowing characteristics of the urine : 

The twenty-four hours' amount is not increased, but 
rather diminished, or more commonly normal. The 
urine is dark-colored and turbid ; its specific gravity 
normal or raised ; the reaction acid ; and often there is 
considerable sediment. 

Of the normal constituents, uric acid is in excess 



DISEASES OF THE URINARY APPARATUS. , 231 

(presence of crystalline uric acid in the sediment and 
proof of a layer of urates by the HN0 3 test). 

Of the abnormal constituents, we find albumen in 
from 0*1 to 0*5 per cent., always more than corresponds 
to the pus and blood in the urine. Also blood-coloring 
matters are constant, though they may be present in very 
small amount. 

The sediment consists chiefly of pointed uric-acid 
crystals, cystine and calcium oxalate, mixed with floc- 
culent pus in greater or less quantity. (PL II., B.) 
Besides these, numerous blood-corpuscles (microcytes) 
and kidney-epithelium cells are visible. 

The symptoms enumerated and the negative results 
from sounding the bladder confirm the diagnosis. 

Pyelitis calculosa admits of a favorable prognosis 
only with concretions of small size, i.e., such as may 
pass through the ureters. With large and branching 
concretions, the prognosis is always unfavorable, or at 
least very dubious. The more severe the suppuration 
and the longer its duration, the more unfavorable the 
prognosis. 

The disease affects usually only one kidney. 

d. Pyelitis Tuberculosa. 

Pyelitis tuberculosa is usually a local expression of a 
general tuberculosis, or a tuberculosis of the genito- 
urinary apparatus. It is on this account not seldom 
complicated with the appearance of a chronic parenchy- 
matous disease of the kidney (nephrophthisis, nephritis 



232 ANALYSIS OF THE URINE. 

ulcerativa). In those cases where tuberculosis of the 
kidney-pelvis is complicated with tuberculosis of the 
kidney, we find in the sediment large, waxy, shining 
cylinders, much molecular detritus, blood- and pus- 
corpuscles, and kidney-epithelium. The urine contains 
a large amount of albumen. 

Simple pyelitis tuberculosa shows, on the contrary, 
the following conditions : 

The amount of the urine is not especially increased. 
The color is dirty yellow, often brown-red from admix- 
ture of blood. It appears always turbid, and has a 
normal or diminished specific gravity and an acid reac- 
tion. The sediment is dirty yellow, often brownish and 
flocculent. 

The excretion of normal constituents is not essen- 
tially altered. 

Of the abnormal constituents, albumen is found in 
from 0*1 to 0*5 per cent., always far in excess of the 
corresponding pus and blood in the sediment. Blood- 
coloring matters are likewise provable in small amount. 

The sediment is brownish, fiocculent, and consists 
chiefly of pus mixed with a small amount of blood. 
Besides this, we find kidney -epithelium and much mole- 
cular detritus mixed with bacteria, which are clotted 
together in spherical and cylindrical shapes. 

The blood-corpuscles of the sediment are generally 
the expression of an ulcerative process in the kidney- 
pelvis, and appear in the night as well as the day urine 
in slightly varying amount ; while in pyelitis calculosa 
the urine passed in the night or after bodily rest shows 



DISEASES OF THE URINARY APPARATUS. , 233 

an appreciable diminution in the amount of blood-cor- 
puscles. The passage of urine with pyelitis tuberculosa 
is not so painful, nor is micturition so frequent, as in 
pyelitis calculosa. Besides this, the usual symptoms of 
lithiasis are wanting. 

Especially supported is the diagnosis of pyelitis 
tuberculosa, if one finds, without other assignable cause, 
swelling of the testicles with tense plastic exudation, 
scrofulous scars, swelling of the glands or other than 
the scrofulous osseous inflammations, and deep and diffi- 
cultly healing rectal fistulse, etc. 

The prognosis is in every case unfavorable when 
there is accompanying tuberculosis. With tuberculosis 
of the genital apparatus, if it occurs in healthy and 
young individuals, there may be improvement, or even 
(for instance, after the extirpation of a tuberculous tes- 
ticle) a relative cure. 

With echinococci in the kidney we find at times an 
accompanying pyelitis, which can not be distinguished 
from the usual chronic form. Only when the echino- 
coccal tumor has perforated the kidney-pelvis do we 
find the characteristic sacs in the sediment; further, 
single scolices with a double-hook arrangement or rem- 
nants of the same and single hooks. (PL VIII., A, 4.) 

Pyelitis with Bilharzia hsematobia is a manifestation 
of existing cystitis. We find the pyelitis in such cases 
complicated with profuse parenchymatous haemorrhage. 
In the sediment, besides numerous blood- and pus- 
corpuscles, and kidney- and bladder-epithelium, we find 
also fibrine flakes which contain the characteristic eggs 



234 ANALYSIS OF TEE URINE. 

of Bilharzia hematobia in great quantity. (See Hema- 
turia, p. 244.) The urine is rich in albumen and dis- 
solved blood-coloring matters. 

The para- or perinephritis can not be recognized 
from the analysis of the urine, since the latter may 
appear normal in very high grades of the diseases. 

2. Hcevnaturia. 

Hematuria in its strictest sense does not belong 
here, since it is but a symptom and no idiopathic disease 
of the urinary apparatus ; but we believe that it should 
be here included, since it very often complicates the 
various diseases of the kidney, the kidney-pelvis, and 
the bladder, often proceeding from simple hyperemia, 
so that one is not always in a position to recognize the 
primary disease. On the contrary, one has very fre- 
quently to content himself with the very general di- 
agnosis, " Hematuria from unknown causes." 

The hemorrhages of the urinary apparatus may be 
divided according to their character into three classes : 

a. Hemoglobinuria (Vogel's hematinuria) ; 

h. Parenchymatous hemorrhage ; 

c. Profuse hemorrhage from rupture of the larger 
vessels. 

I. Hcemoglohinuria betrays itself by a reddish-brown, 
brownish-black, or at times lake-colored urine, which 
even after standing for hours deposits no red sediment 
of blood-corpuscles. It retains its homogeneous red- 
brown color, because the blood-coloring matters are in 



DISEASES OF THE URINARY APPARATUS. 235 

solution. The reaction is generally acid and the specific 
gravity lowered. The urine contains a great mass of 
haemoglobine and methaeinoglobine. In the sediment 
we find at times epithelial (hemorrhagic) and molecular 
detritus, colored brown by the coloring matters of the 
blood. 

II. Parenchymatous hemorrhage exhibits a red- 
brown, often coffee-colored urine, which after long stand- 
ing retains its homogeneous red-brown color, but which, 
however, deposits a sediment, though often very slight, 
colored red-brown by blood- corpuscles. It generally 
reacts acid, has a varying specific gravity, and contains 
in solution more or less altered haemoglobine. 

The sediment is characteristic of parenchymatous 
haemorrhage. We find in it blood-corpuscles of various 
sizes. Often normal disk-formed corpuscles are seen, 
with a rather indistinct depression ; they also appear 
roundish, spherical, and colored somewhat brown. Fre- 
quently they are quite colorless, without fluid contents, 
similar to small rings. 

In the field we often observe, besides the greater 
spheres, corpuscles only half or a quarter the usual size, 
and still smaller, down to fine dust-particles. 

These microcytes, which in the last few years have 
been seen so often in the blood of patients, are charac- 
teristic of parenchymatous haemorrhages of the urinary 
apparatus, and have been recognized as such for a long 
time. 

III. Profuse haemorrhage from the large vessels. — In 
this case Ave find the urine colored dark reddish-yellow, 



236 ANALYSIS OF THE URINE. 

or red, similar to venous blood. The reaction is usually 
neutral or alkaline, and the specific gravity is varying. 
The urine contains generally only traces of blood-color- 
ing matters in solution ; only when the urine is strongly 
alkaline from carbonate of ammonia — and this is but 
seldom — considerable blood-coloring matters are found 
in solution. 

Usually such urine deposits its entire blood as a 
considerable bright-red sediment after a few hours, and 
then appears of a normal yellow color. 

Albumen arising from blood-serum is always present 
in the urine. The sediment consists throughout of nor- 
mal disk-form corpuscles, in size similar to those of nor- 
mal blood. Sometimes there appear also in the sedi- 
ment blood-clots of various shapes. 

These three forms of haemorrhage can occur as well 
from the bladder as from the kidney-pelvis and the kid- 
ney, and consequently one is not always fortunate enough 
to know exactly from what part of the urinary appara- 
tus the haemorrhage originates. 

1. The reaction should be first considered for the 
differential diagnosis. We find usually, that the urine 
accompanying haemorrhage of the kidney is acid, and 
with haemorrhage of the bladder it is alkaline. This, 
however, is not always the case ; for these conditions 
only hold when the haemorrhage is complicated with a 
purulent catarrh, either of the kidney-pelvis or of the 
bladder. Here, also, the reaction with litmus is not 
always to be relied upon ; for, with a profuse haemor- 



DISEASES OF THE URINARY APPARATUS. 237 

rhage through bursting of one of the greater vessels, the 
alkalinity of the blood may overcome the acidity of the 
urine, and we may find, in spite of the fact that the hae- 
morrhage does not come from the bladder, an alkaline 
reaction. In like manner the urine might become alka- 
line from the internal use of alkalies or alkaline mineral 
waters. Or perhaps the pyorrhoea of the kidney-pelvis 
might be so profuse that the alkali of the pus-serum 
could overcome the acidity of the urine. In such cases 
we would have an alkaline reaction of the urine from 
haemorrhages which had not their origin in the bladder. 

On the other hand, it must not be denied that 
haemorrhages do occur in the bladder where the urine 
shows an acid reaction. This appears constant when 
there is no purulent catarrh of the bladder, and when 
the haemorrhage is not profuse. 

The reaction of the urine with litmus alone is not 
sufficient for locating the haemorrhage. 

More important for this determination is the proof 
of a large amount of ammonium carbonate ; for when 
this is present in quantity, the probability is great that 
the haemorrhage is from the bladder, especially if at the 
same time crystals of ammonio-magnesium phosphates 
appear in the sediment. (PL IV., B.) 

2. The color of the urine should have even more 
weight than the reaction with litmus. The older prac- 
titioners connected the red-brown and brown-black 
shades of the urine with kidney-haemorrhages, and the 
bright -red color with haemorrhages from the bladder ; 
this, however, is not always the case. The brown, red- 



238 ANALYSIS OF TEE URINE. 

brown, and brown-black tones of the urine arise from 
decomposed haemoglobine (methaemoglobine), and can 
only occur in those cases where the blood has been inti- 
mately mixed with the urine for a long time, at the tem- 
perature of the body — i. e., within the urinary apparatus. 
"We find usually such a condition with parenchymatous 
haemorrhage ; the blood mixes gradually drop by drop 
with the urine, the corpuscles remaining for a long time 
with a relatively great amount of fluid matters, the 
products of retrograde tissue-metamorphosis. By this 
intimate mixing the urinary constituents have time to 
exert their destructive influence on the blood-corpuscles, 
and finally to change the red haemoglobine to the brown 
methaemoglobine. 

For this reason parenchymatous haemorrhages from 
the bladder (carcinoma of the bladder) also give to the 
urine the red-brown and brown-black color. 

It is quite otherwise, however, with profuse haemor- 
rhage, caused by the rupture of large vessels (bladder- 
haemorrhoids). In such cases, at one time a great quan- 
tity of blood enters the urinary apparatus, especially the 
bladder, and quickly distends it. The unusual disten- 
tion is followed by immediate contractions of the blad- 
der, micturition ensues, and blood is passed before the 
urine has had time to decompose the haemoglobine. 

Since bladder-haemorrhages arise mostly through 
rupture of the vessels, and kidney-haemorrhages, on the 
other hand, are mostly parenchymatous, the brown-red 
color of the latter and the bright blood-red color of the 
former are of value for the diagnosis. 



DISEASES OF THE URINARY APPARATUS 239 

3. The specific gravity of the urine has a diagnostic 
value, inasmuch as we find generally, from hemorrhage 
of the kidney and kidney-pelvis, such a condition of the 
organs that polyuria ensues (pyelitis), in consequence of 
which the specific gravity is lowered, while with bleed- 
ing from the excretory passages there seldom arise dis- 
eases (cystitis) which cause polyuria ; hence in the latter 
case the specific gravity is normal. 

4. Blood-coagula. — The form of the clots when pres- 
ent in the urine sometimes shows with certainty the 
location of the haemorrhage. 

If the coagula are soft and have the color and con- 
sistence of freshly clotted blood, then they have not 
existed for a long time. If, however, they are without 
color or appear somewhat dirty yellow, they are of older 
date and have been retained in the urinary apparatus a 
longer time. Likewise short rod-shaped clots arise at 
times from the distended kidney-pelvis (Simon), and 
appear in the urine after haemorrhage from the kidneys. 
These were formerly considered as concretions, and 
thought to consist of pure fibrin. (Heller.) 

The coagula which occur long and rod-shaped indi- 
cate a haemorrhage from the kidney, while the lumpy, 
torn, irregular masses should come from the bladder. 
Further than this, it must be emphasized that only the 
long and rod-shaped blood-clots afford a certain indica- 
tion of the place of origin of the haemorrhage. If such 
forms occur, the seat of the difficulty must be above the 
ureters, for the rod-shapes are caused by passage of the 
clots through the same. We have seen a case, where a 



240 ANALYSIS OF TEE URINE. 

man forty-nine years old, suffering from a palpable neo- 
plasm of the right kidney (with hematuria), repeatedly 
passed blood-clots 10 to 15 centimetres long, as thick as 
a lead pencil. The irregular lumps are not very charac- 
teristic, for they may occur from the kidney-pelvis as 
well as from the bladder. Blood may also pass in a 
fluid state from the kidney to the bladder, and then 
coagulate. 

Coagula are not constant in connection with hema- 
turia. Parenchymatous and profuse haemorrhages only 
seldom give rise to clots ; consequently they occur most 
frequently when the bleeding arises from vessels of small 
calibre. 

5. The microscopic analysis furnishes the greatest 
aid to the differential diagnosis of hsematuria. 

The so-called blood-cylinders (PL V., A) and the 
haemorrhagically tinged kidney-epithelium are character- 
istic of parenchymatous kidney-haemorrhage. In severe 
kidney-haemorrhages, however (if they are from vessels 
of large calibre), we do not find them. It is very prob- 
able that kidney-epithelium, at least in single cells, is 
present in the* sediment ; but the great mass of blood 
present conceals these cell-forms, so that one sees 
nothing but blood-corpuscles under the microscope. 

Bladder-haemorrhages are often not characterized by 
any microscopic indications. At times we find in the 
sediment an increased amount of bladder-epithelium and 
crystals of ammonio-magnesium phosphate. 

Having described the micro-chemical characteristics 



DISEASES OF THE URINARY APPARATUS. 241 

of hematuria (haemorrhages of the urinary apparatus) 
in general, we will now mention those diseases which 
afford opportunities of observing them, and in every 
case where it is possible endeavor to furnish new 
grounds for diagnosis. 

I. Hcemoglohinuria (with or without inethaemoglo- 
binuria) occurs with haemophilia, scurvy, malignant 
intermittent fever, putrid typhus fevers, and especially 
with those diseases which are accompanied by a so- 
called dissolution of blood; also after inhalation of 
hydrogen arsenide, carbonic acid, and similar gases. 
After the transfusion of animal blood we frequently 
observe haemoglobinuria, especially in those cases where 
a considerable quantity of animal blood has been intro- 
duced into the human organism. 

II. Parenchymatous haemorrhage may, as already 
stated, come from the kidney (and its pelvis) or the 
bladder, or from the entire urinary apparatus. 

a. Haemorrhage from the Mdneys, besides the above- 
mentioned cases, is found usually with haemoglobinuria 
in the following : 

1. Sometimes with acute febrile processes, especially 
with exanthemata, where the haemorrhage represents at 
the same time a high degree of hyperaemia. 

2. In the majority of cases of acute and chronic 
parenchymatous nephritis. 

3. Eegularly with atheromatous degeneration of the 
kidney-vessels. 

4. With thrombosis of the renal veins, as in general 

cachectic conditions, puerperal fever, not seldom with 
16 



242 ANALYSIS OF THE URINE, 

uterine and crural phlebitis (Cruveilhier, "Anatomic," 
Livre 36) ; further, in consequence of severe injuries of 
the kidney, at times along with traumatic nephritis; 
also from thrombosis produced by compression of tu- 
mors in the vicinity of the hilus. 

With nurslings who suffer from enteritis there at 
times occurs a thrombosis of the renal veins. Accord- 
ing to O. Pollak, one observes that after the termination 
of a diarrhoea children become icteric, a considerable 
diminution of the urinary excretion takes place, and in 
the sediment are found blood-cylinders, blood-corpuscles, 
and hemorrhagic epithelium. 

Further, kidney haemorrhages are observed — 

5. Constantly with renal calculi, although no severe 
pyelitis may be present. We find then in the sediment, 
besides blood-corpuscles of various sizes and kidney- 
epithelium, jagged crystals of uric acid or calcium 
oxalate. 

6. With cancer of the kidney, besides the parenchy- 
matous haemorrhage, we find nothing striking. Cancer- 
cells and cancerous tissue we have not found in the sed- 
iment of the urine ; still the possibility is not excluded 
that, if the cancer develops in the kidney-pelvis, we 
might find carcinomatous tissue in the sediment. In 
small children palpable tumors of the kidney as large 
as the fist are frequently observed, with no indications 
in the urine but a slight albuminuria. Hematuria is 
therefore not a constant but a very frequent symptom 
of new growths in the kidney. 

7. With renal phthisis or with cheesy inflammation 



DISEASES OF THE URINARY APPARATUS. , 243 

of the kidney, the kidney-pelvis, and the ureters, we find 
in the sediment, besides microcytes, kidney-epithelium, 
pus-corpuscles, much molecular detritus, great quantities 
of vibriones and micrococci, and at times waxy cylinders, 
together with such as consist of vibriones and micrococci. 
b. Hemorrhage from the bladder is observed — 

1. With stone in the bladder and with catarrhal ul- 
cerations of its neck. The hematuria is of a lighter 
grade. 

In both cases, however, small blood-corpuscles (mi- 
crocytes) are not observed in the sediment. All are of 
normal size. If a complicating bladder-catarrh is present, 
the urine reacts alkaline, and in the sediment we find, 
besides blood- and pus-corpuscles, crystals of ammonio- 
magnesium phosphate and bladder-epithelium. 

Hematuria from bladder-stone becomes worse by 
exercise. The patient, therefore, should rest in bed. 
The hematuria from catarrhal ulcerations, which occurs 
in the neck of the bladder usually after gonorrhoea, 
exhibits itself toward the close of micturition, when the 
sphincter vesicae begins to contract. 

2. With papilloma of the bladder and with carcinoma 
villosum arises also parenchymatous haemorrhage from 
the papillary growth of the mucous membrane. In the 
sediment we find not infrequently beautifully recogniz- 
able necrotic cancer-tissue, which confirms the diagnosis. 
However, one single microscopic investigation of the 
sediment does not suffice, since the cancer-tissue is not 
voided at each micturition. (For further particulars see 
section on villous cancer of the bladder.) 



244 ANALYSIS OF THE URINE. 

c. Parenchymatous hemorrhage from the entire uri- 
nary apparatus occurs — 

1. Sometimes after the evacuation from a paretic or 
paralyzed bladder and after catheterization. If for sev- 
eral years, on account of a paralyzed bladder, a portion 
of the urine had been accustomed to remain in it after 
micturition, and suddenly the entire amount is drawn 
off by a catheter, there arises necessarily a hyperaeinia 
ex vacuo, which becomes the more intense accordingly as 
the muscles of the bladder have become hypertrophied, 
rendering complete contraction impossible. Since also 
the secretory pressure in the kidney, which before was 
obliged to overcome the weight of the residual urine in 
the bladder, meets with no such resistance after cathe- 
terization, a parenchymatous haemorrhage ensues. 

2. Parenchymatous haemorrhage from the entire ap- 
paratus, but especially from the bladder, is observed in 
Egypt as a consequence of Bilharzia haematobia. There 
arises embolism of the vessels of the mucous membrane 
caused by the eggs of the Distoma haematobium. In 
such cases we find in the sediment, as already mentioned, 
little blood-coagula which the microscope shows to be 
imbedded with the long oval eggs of these parasites. 

III. Severe hemorrhages of the large vessels occur only 
from new growths and a varicose condition of the neck 
of the bladder. 

With new growths (villous cancer of the bladder) 
they only occur profusely when the cancer has existed 
for a long time and becomes ulcerated. "With the so- 
called bladder-haemorrhoids the bleeding takes place so 



DISEASES OF TEE URINARY APPARATUS. , 245 

suddenly and profusely that the patient after one or 
two days becomes quite anaemic. It takes usually only 
a few days to destroy a perfectly healthy condition. 
Such haemorrhages may occur after several months or 
several years. In the sediment we find nothing but 
blood-corpuscles of normal size and character. 

In diphtheritic and croupous processes in the blad- 
der, such as occur in consequence of so-called blood-dis- 
solution, we find also blood in the ichorous, putrid, and 
alkaline-reacting urine. 

3. Cysto-Pyelitis and Py eh- Cystitis. 

By these terms we understand a purulent catarrh 
which at the same time has involved the pelvis of the 
kidney, the ureter, and the bladder. If the pelvis of 
the kidney is principally the seat of the disease, it is 
designated as cysto-pyelitis ; if however the bladder is 
most involved, then the disease is called pyelo-cystitis. 
Whether pyelitis or cystitis predominates is determined 
by the prevailing characteristics of the disease. 

If pyelitis prevails, polyuria is generally present, the 
urine has a neutral or slightly alkaline reaction, the 
specific gravity will be lowered, and the purulent sedi- 
ment will not stick to the glass. Albumen is found in 
greater proportion than the contained pus warrants, and 
in the sediment we find (besides pus-corpuscles) kidney- 
and bladder-epithelium and isolated triple-phosphate 
crystals. The pus-corpuscles seem to be well preserved, 
and sometimes to be pressed together in cylindrical 
masses. 



246 ANALYSIS OF THE URINE. 

If, on the contrary, cystitis prevails, then polyuria is 
not present, and the urine reacts strongly alkaline and 
has a normal or slightly lowered specific gravity. The 
sediment is glutinous, and the alkaline pus sticks to the 
glass. Albumen is present in greater mass than corre- 
sponds to the contained pus. Carbonate of ammonium 
is present in considerable amount. 

In the sediment we find the pus-corpuscles much 
swollen and a great abundance of triple phosphates ; we 
also find isolated scales of kidney- and bladder-epithe- 
lium. 

Cysto-pyelitis and pyelo-cystitis occur very frequent- 
ly with stricture of the urethra, hypertrophy of the 
prostate, and with paresis or paralysis of the bladder. 

From cystitis or from pyelitis arises very often, 
through contiguity, cysto-pyelitis or pyelo-cystitis. It 
even happens that cystitis alternates with pyelo-cystitis 
and pyelitis with cysto-pyelitis. 

Cysto-pyelitis as well as pyelo-cystitis can be caused 
by all those noxious circumstances which bring about 
cystitis and pyelitis. (See sections on Cystitis and Pye- 
litis.) 

The prognosis depends upon the setiological indica- 
tions and the severity of the prevailing disease. 

C. Forms of False Albuminuria. 

The false albuminuria differs from the true and 
from the mixed form, in that the albumen is always 
present in quantities corresponding to the contained 



DISEASES OF THE URINARY APPARATUS. 247 

pus or blood. The albumen found is that of the pus or 
blood-serum. If both suddenly disappear from the 
urine — for instance, a few days after the opening of an 
abscess in the bladder, or as happens after the bursting 
of a varix in the neck of the bladder — then the albumen 
also disappears from the urine. 

From the foregoing we see that true albuminuria is 
only brought about by changes in the kidney, while the 
origin of the false is always in the excretory passages 
and bladder. During the diseases of the pelvis of the 
kidney, on account of the immediate contact with the 
kidney proper, a form of mixed albuminuria occurs, 
which we have previously alluded to. There remains 
much to be said concerning the diseases of the bladder 
and urethra, for these give rise to different forms of false 
albuminuria. 

1. Cystitis — Bladder- Catarrh. 

We distinguish a chronic and an acute bladder- 
catarrh, and with each of these three grades. 

In bladder-catarrh of the first grade, the urine con- 
tains neither albumen nor pus, but simply a much 
increased mucus, and possesses a slight acid reaction. 
In the second grade the urine reacts alkaline, contains 
albumen and pus, and has a glutinous greenish sediment. 
In the third grade we have a putrid viscous urine with 
a strongly alkaline reaction, containing much albumen, 
pus, and blood. This is followed by ulcerative pro- 
cesses in the bladder, often complicated with suppura- 
tive nephritis. 



248 ANALYSIS OF TEE URINE. 

The urine from bladder-catarrh shows generally an 
alkaline reaction, and many practicing physicians diag- 
nose this by the litmus test. 

While this is generally true, there are also cases 
when with cystitis the urine gives an acid reaction. 
This is for the most part noticeable in freshly passed 
urine, which, however, becomes alkaline in a few hours. 

a. Acute Bladder-Catarrh, first grade. 

Conditions. — The amount of urine is not increased; 
it has a normal or dark wine-yellow color and is turbid. 
The specific gravity remains unchanged. The reaction 
is weakly acid, but in a few hours becomes alkaline. 
The sediment is considerable, but cloudy, not compact. 

The normal constituents are unchanged. 

Of the abnormal constituents, we find carbonate of 
ammonium in small amount ; albumen is not pres- 
ent. 

The sediment consists chiefly of an increased cloudy 
mucous secretion. Microscopically we find mucus-cor- 
puscles (young* cells) and a small amount of bladder- 
epithelium. After a few hours we find also single crys- 
tals of ammonio-magnesium phosphate. 

The acute bladder-catarrh of the first grade represents 
generally a partial disease of the mucous membrane, 
such as occurs with prostatitis after gonorrhoea, or after 
instrumental investigation of the bladder and urethra. 
In women with malpositions of the uterus such a blad- 
der-catarrh usually accompanies menstruation. 



DISEASES OF THE URINARY APPARATUS. . 249 

h. Chronic Bladder- Catarrh, first grade. 

This form is characterized by a wine-yellow, very tur- 
bid urine, with a normal specific gravity, and whose 
twenty-four hours' amount is not increased. The reac- 
tion when first passed is acid, but in a few hours changes 
suddenly to alkaline. The sediment is considerable and 
cloudy. Sometimes the' urine, when freshly passed, with 
an acid reaction has a peculiarly strong urine odor. The 
turbidity does not settle, and consists in great part of 
bacteria. 

The excretion of normal constituents is not al- 
tered. 

Of the abnormal constituents, carbonate of ammo- 
nium is present in small quantity ; albumen is not pres- 
ent. 

The sediment consists mainly of an increased cloudy 
mucous secretion, with bacteria. Microscopically we 
find single mucus-corpuscles, and also bladder-epithe- 
lium. After a few hours we find single triple-phosphate 
crystals in the sediment. 

Such urine is constant with persons who find them- 
selves obliged to employ catheters for the passage of 
urine, as with hypertrophy of the prostate, paresis of 
the bladder, and similar hindrances to urination. This 
first stage of bladder-catarrh occurs without exception 
in old women who have borne many children, or have 
been subjected to circumstances which lead to diseases 
of the uterus. 



250 ANALYSIS OF THE URINE. 

c. Acute Bladder- Catarrh, second grade. 

This differs from the first grade chiefly by the pus 
contained in the urine. 

The urine has a dark wine-yellow color, and is tur- 
bid. The turbidity consists of mucus and pus, while in 
the first grade we only find mucus. The specific gravity 
is normal. The twenty-four hours' amount is not in- 
creased. The reaction of the freshly passed urine is 
alkaline. The sediment is greenish-yellow, and sticks 
fast to the glass. 

The excretion of the normal constituent is only so 
much altered that a part of the urea has changed to car- 
bonate of ammonium. 

Of the abnormal constituents, albumen is present 
in amount corresponding to the pus contained in the 
sediment ; ammonium carbonate is present in consider- 
able quantity. 

The sediment consists principally of an alkaline pus 
mixed with crystalline and amorphous earthy phosphate. 
Microscopically we find single blood-corpuscles, urate of 
ammonia, and much bladder-epithelium. 

Such urine is found with hypertrophy of the pros- 
tate, after using the lithotrite on large and hard stones, 
after dilatation of strictures, after catheterization and 
other instrumental investigations ; further, through con- 
tinuity, with gonorrhoea and acute prostatitis ; and final- 
ly, after catching cold, especially from exposure to cold 
and moisture. In women, an acute bladder-catarrh with 
pus is sometimes observed after operation on the uterus 



DISEASES OF TEE URINARY APPARATUS. 251 

and vagina, with perimetritis and pericystitis, and after 
exhibition of cantharides, copaiva, and similar powerful 
drugs. Badly fermented new beer should also be enu- 
merated as a cause. 



d. Chronic Bladder- Catarrh, second grade. 

Characteristics. — A turbid wine-yellow urine, the tur- 
bidity being caused by pus-corpuscles and bacteria, while 
in the chronic bladder-catarrh of the first grade it is oc- 
casioned by mucus and bacteria. The twenty-four hours' 
amount is not increased. The specific gravity is normal. 
The reaction even when passed is alkaline. The sedi- 
ment is greenish-yellow and sticks to the glass. 

The excretion of the normal constituents, as also in 
the acute catarrh, is only so much altered that a greater 
part of the urea has changed to carbonate of ammonium. 

Of the abnormal constituents, we find albumen in 
the urine in amount corresponding to the pus in the 
sediment, and much carbonate of ammonium. 

The sediment consists chiefly of alkaline pus mixed 
with crystalline and amorphous earthy phosphates. 
The pus-corpuscles are found greatly distended, their 
contour destroyed, and their nuclei coming out. Often 
we only find free nuclei, imbedded in a homogeneous, 
turbid, ground sediment, and besides these bacteria and 
single bladder-epithelium cells. 

Often the pus is completely dissolved in a urine rich 
in ammonium carbonate, whereby the urine becomes 
sirupy and has a stringy consistence. 



252 ANALYSIS OF THE URINE. 

Sucli urine is found with hypertrophy of the pros- 
tate, paresis of the bladder, and with serious strictures 
and similar impediments to the urinary excretion. 

e. Acute Bladder- Catarrh, third grade. 

This grade embraces those processes which are 
designated as parenchymatous cystitis and pericystitis. 

While we are unable always to diagnose these dis- 
eases by the investigation of the urine alone, it assists 
the diagnosis very materially, in that by the analysis we 
can not overlook a severe form of purulent bladder- 
catarrh. 

If the amount of pus is very disproportionate, then 
we may suspect the discharge of a bladder-abscess. 

The uroscopic indications are similar to those of 
acute bladder-catarrh of the second grade, with the 
exception that the purulent sediment does not stick to 
the glass and is mixed with blood in greater proportion. 
Albumen is present in larger amount than corresponds 
to the pus and blood contained in the urine. 

/. Chronic Bladder- Catarrh, third grade. 

This is a purulent catarrh complicated with ulcer- 
ative processes in the bladder. 

The urine is of a dirty brown-yellow color, and has 
a cadaverous odor. The reaction is strongly alkaline. 
The turbidity proceeds from bacteria and blood- and 
pus-corpuscles. The specific gravity is elevated. The 
sediment is dirty yellow and sticks to the glass. 



DISEASES OF THE URINARY APPARATUS. 253 

The excretion of normal constituents is diminished. 

Of the abnormal constituents, we find much albu- 
men, blood-coloring matters, carbonate of ammonium, 
and sulphide of ammonium. 

The sediment consists of alkaline-reacting pus mixed 
with blood and earthy phosphates. Microscopically we 
observe in large quantities bacteria, molecular detritus, 
and single cells of bladder-epithelium. 

This process comes from paralysis of the bladder 
and high stages of prostatic hypertrophy. It is com- 
plicated by suppurative nephritis or pyelo-nephritis. 
The appearance of' uraemia or ammonaemia then closes 
the scene. 

Similar urine comes with tuberculous ulcerations of 
the bladder and with diphtheritis. 

With croupous processes in the bladder, which some- 
times occur with women, very large plates of reddish- 
white membrane are excreted with the urine, which 
consist of fibrine. They are often from the size of a 
half dollar to that of the hand. 

Very often upon the passage of the urine cysto- 
spasmus is confounded with bladder-catarrh, because 
the symptoms of both diseases are very similar. The 
investigation of the urine alone can determine the dif- 
ferential diagnosis. 

With vesical spasms the urine is generally clear, and 
in case of turbidity this arises from earthy phosphates 
which come down on excretion. The urine is moreover 
pale, and reacts weakly acid or neutral. 

By the heating test the urine becomes turbid, for by 



254 ANALYSIS OF THE URINE. 

this means the earthy phosphates and carbonates fall, 
which are again dissolved on addition of acetic acid. 
Sodium carbonate is also sometimes present. 

Albumen, pus, ammonium carbonate, etc., in contra- 
distinction to cystitis, are not present. 

In the sediment we find calcium carbonate, crystal- 
line calcium phosphate, and amorphous earthy phos- 
phates. Triple phosphates and bladder-epithelium are 
wanting. 

2. New Growths in the Bladder. 

Since the haemorrhages of the bladder and their 
^etiological conditions have been described in the sec- 
tion on haematuria, we will only allude to them in so far 
as they are in close connection with bladder forma- 
tions. 

The following growths are found in the bladder : 

(a.) Simple fibrous polypi, which project into the 
cavity of the bladder ; these are of rare occurrence. 

(5.) Medullary sarcoma ; also of rare occurrence. 

(c.) Epithelioma. 

(d.) Villous or vascular tumors. 

1. Fibrous polypi cause simply a bladder-catarrh of 
the second grade, and only when ulcerated do we find 
blood in greater or less amount in the sediment. 

~No histological elements characteristic of this form 
of tumor are found in the sediment. We can not there- 
fore diagnose this formation from the analysis of the 
urine. 

2. Medidlary sarcoma. — The same is true of medul- 



DISEASES OF THE URINARY APPARATUS. , 255 

lary sarcoma, except that in later stages it causes a 
bladder-catarrh of the third grade. The urine is at times 
greenish-brown, with a strongly putrid odor. In the 
sediment we find much molecular detritus, but other- 
wise no characteristic elements which serve for the 
diagnosis. 

3. Epithelioma generally develops slowly, and some- 
times occasions a bladder-catarrh of the second and 
sometimes of the third grade. The sediment is always 
more or less blood-colored. 

The microscopic investigation develops oftenest (be- 
sides blood- and pus-corpuscles) numerous peculiar small 
epithelial cells, which now and then appear in such 
large quantity that their number seems to equal the pus- 
corpuscles. 

The epithelial cells are small, round or oval, not dis- 
similar to kidney-epithelium. Sometimes they may be 
caudate, showing two or three small projections. The 
nuclei are frequently very large and brightly glistening, 
and several are visible in the same cell. Sometimes ten 
or twelve of these cells hang together and form an epi- 
thelial shred. (PL VIII., B.) 

One is not justified in diagnosing epithelioma from 
the appearance of the various cell-forms in the sediment. 
If, however, a suspicion exists as to its presence, it is 
greatly strengthened by the indications of the micro- 
scopic investigation. 

4. Villous or vascular tumors can always be recog- 
nized from the investigation of the urine. 

At times two kinds may be distinguished : 1st, the 



256 ANALYSIS OF THE URINE. 

papillary growth (papilloma) of the mucous membrane ; 
and 2d, villous cancer proper. 

Parenchymatous haemorrhages are common to both 
forms, which may be accompanied by a bladder-catarrh 
of the second or third grade. In the first case only, 
after the sloughing off of the papillary growth which 
has become necrosed, healing may take place ; while in 
true villous cancer a cachectic condition arises, which 
soon carries off the patient. 

The villous cancer consists of a more or less soft 
mass, which, being of the consistence of medullary tis- 
sue, appears to involve the back and under wall of the 
bladder, so that the thickening or tumor may be felt by 
introducing the finger into the rectum. Upon this 
tumor, forming at the same time its covering, the true 
cancerous tissue develops itself. This consists of dilated 
capillary vessels and a thinner or thicker layer of epi- 
thelium. 

Papilloma of the bladder, on the contrary, is confined 
simply to the mucous membrane. We are unable to 
find a thickening of the bladder-wall or a tumor from 
rectal investigation. 

From the fact that such a difference exists between 
these two forms of bladder-growth, the question arises 
whether we may not be able to diagnose them with cer- 
tainty from urinary investigation alone. This, however, 
is not possible, because not infrequently papilloma of 
the bladder after a time passes over into villous cancer. 
Although there are some characteristic indications for 
the microscopic recognition of villous tissue, they are 



DISEASES OF THE URINARY APPARATUS. 257 

not sufficient to insure a correct differential diagno- 
sis. 

If we find beautifully constructed villous tissue in 
fine branches, with a very thin epithelial covering, we 
generally suppose that we have to deal with a papillary 
growth in the bladder. If, on the contrary, we find 
villous tissue with a thick epithelial covering, so that 
one can not distinguish the broadened vessels of the 
villus, we conclude usually that we have a villous can- 
cer to treat. 

These indications from the urine are, however, less 
weighty than the local proof of a swelling in the blad- 
der-wall and the accompanying cachectic condition. 

On account of the difficulty in separating these two 
forms of villous tumor of the bladder, it seems proper 
to treat them here as possessing characteristics common 
to both. 

The urine shows the following characteristic indica- 
tions with villous tumors : 

The twenty-four hours' amount is increased. The 
specific gravity is normal. The color of the urine, as 
with parenchymatous haemorrhage, is red-brown to 
brown-black. The turbidity is due to blood- and pus- 
corpuscles. The reaction is generally, though weakly, 
acid. Only when the villous tumor begins to increase 
rapidly, and the accompanying bladder-catarrh causes a 
greater excretion of pus, does the urine possess an alka- 
line reaction. The sediment is fine and flocculent, 
brownish to brown-red in color, and contains reddish or 

fiesh-colored little fibres or larger similar shreds. 
17 



258 ANALYSIS OF TEE URINE 

The consistence of the urine is usually that of a thin 
fluid, though there occurs sometimes with villous tumors 
(but only temporarily) a fibrinuria with its peculiar 
gelatinous appearance. This is the only disease of the 
urinary organs in our latitudes in which even a transi- 
tory fibrinuria has been observed. 

The urine when freshly passed appears as a thin 
fluid; but in a few minutes it suddenly stiffens to a 
jelly-like mass, which can scarcely be poured from the 
vessel. After long shaking the urine again becomes 
fluid, and may be used for further investigation. The 
color of the urine with fibrinuria is not always in- 
tensely bloody, but sometimes only slightly reddish 
yellow. 

Fibrinuria (with villous tumor) is always accom- 
panied by severe strangury. One can easily understand 
that with strong spasmodic muscular contractions of the 
bladder a compression of the blood-vessels penetrating 
the muscular layer follows. Since the veins, because of 
the thinness of their walls, are more compressible than 
the arteries, there must arise a stasis in the vessels of 
the villous tumbr. If the tension is very great in the 
vessels, a rupture of them may occur, and haemorrhage 
into the bladder ensue. If, on the other hand, the ten- 
sion is not sufficient to rupture the vessel- walls, then the 
plasma exudes from the capillaries, and coagulates after 
the excretion of the urine because of the contained 
fi brine. 



-X- 



* Such a fibrinuria caused by severe strangury has been observed by us 
in three cases. 



DISEASES OF TEE URINARY APPARATUS. , 259 

The excretion of normal matters with villous tumors 
is not altered. 

Of the abnormal constituents, albumen and blood- 
coloring matters are found in considerable quantity. It 
is especially to be remarked, that with villous tumors 
there is always more albumen in the urine than corre- 
sponds to the amount of pus or blood in the sediment. 
This condition depends upon the increased tension with- 
in the supplying vessels of the villous tissue. 

Since these appearances, accompanied at the same 
time by an acid reaction of the urine, are very similar to 
the indications of true albuminuria, one must be ex- 
tremely careful in such cases not to diagnose a kidney- 
affection without having distinctly recognized kidney- 
cylinders in the sediment. This precaution is the more 
necessary, as the inexperienced may easily confuse single 
delicate villous shreds with kidney-cylinders. 

Ammonium carbonate is not always provable. 

The flocculent sediment is usually brownish, with 
severe bladder-catarrh dirty yellow, and with profuse 
haemorrhage after rupture of a blood-red color. The 
more blood or pus the urine contains, the more difficult 
it is to recognize the characteristic tissue-fibres which at 
times are very sparingly present. With profuse haemor- 
rhage especially it is only an accident if in the great 
amount of blood one finds a characteristic lump. With 
a purulent sediment one must also be very careful, al- 
though the red lumps or flakes are much easier to be 
found in the greenish pus than in the dark blood. We 
therefore choose a comparatively clear and less bloody 



260 ANALYSIS OF THE URINE. 

urine for the search for villous tissue. After the sedi- 
ment has sufficiently settled, it should be emptied upon 
a watch-glass, and the red flakes removed on a needle or 
pincette and placed under the microscope. 

The chief constituent of the sediment is blood alone, 
or blood mixed with pus. The blood comes mostly in a 
fluid state, though frequently we observe clots of various 
sizes in the sediment. These are distinguished from 
villous tissue by the fact that they appear dark black- 
red, while the latter are usually flesh-colored. Often, 
however, we find villous tissue inclosed in the clots 
of blood. The blood-corpuscles show the same forms 
as in parenchymatous haemorrhage ; we find them of 
various sizes and spherical shape (microcytes). 

Villous tissue appears in various forms, according as 
the urine possesses an acid or alkaline reaction. It is an 
error to suppose that the villous tissue appears as beau- 
tiful and unchanged as is generally represented in the 
text-books. An unchanged representation of the living 
villous tissue never occurs in the sediment. Such can, 
however, be observed when accidentally a small frag- 
ment of the ' fresh growth has been detached and 
brought out in the orifice of the catheter. Usually 
only necrotic villous tissue is perceived, and this under 
the microscope may appear in numerous forms. These 
become necrotic and are cast off by the bursting of ves- 
sels in the villus. 

In the commencement of the disease we find the 
most perfect villous tissue, We observe/then not in- 
frequently, under the microscope, a small shred-like 



DISEASES OF TEE URINARY APPARATUS. , 261 

structure, from which, the tissue extends similar to the 
fringe of a napkin. The thinner the epithelial covering, 
so much more distinctly are seen the villi. Since the 
necrotic villi and their vessels are for the most part rup- 
tured, we find but seldom unaltered blood-corpuscles in 
the lumen of the dilated tubes. Beautiful villous tissue 
is found especially with papillary hypertrophy of the 
mucous membrane of the bladder. (PL VIIL, B.) 

One is not always so fortunate in his investigations ; 
for, especially with the proper villous cancer, having a 
thick epithelial covering, it is very difficult to find dis- 
tinct villi. The epithelial covering of the necrotic villi 
is in a state of molecular disintegration, so that the 
divisions of the single cells are no longer apparent. It 
is infiltrated with blood- and pus-corpuscles and teeming 
with bacteria. Sometimes one sees in this molecular 
mass true branching forms which show the ground- 
structure and blood-vessels of the villous tissue. 

Although histologically in such cases we have no 
characteristic points for recognizing true villous tissue, 
yet there are other very important microscopic data 
which confirm the diagnosis of the same. They are as 
follows : 

Under a high power of the microscope, if one ex- 
amines the necrotic tissue, we find single spots of the 
epithelial covering colored brownish. On examining 
these spots more carefully, we observe, if the urine 
possesses an acid reaction, beautiful yellow or brown 
rhombic plates of haBmatoidine, and yellow grassy forms 
which consist of the same coloring matter. If we per- 



262 ANALYSIS OF THE URINE. 

mit a drop of H]ST0 3 (fuming) to now under the cover- 
glass, then we observe under the microscope that the 
brown-yellow spot, and even the entire necrotic villous 
tissue, becomes successively green, blue, and violet. 
Hsematoidine is a characteristic proof of old hemor- 
rhagic tissue, and is to that extent of diagnostic signifi- 
cance for bladder-cancer. 

In such necrotic pulpous tissue not seldom peculiar 
crystals are found, which, as we learn from better pre- 
served specimens, are peculiar to villous tissue, and are 
found in the urine only in connection with it. These 
are small, colorless, round rosettes, which are only 
soluble in concentrated acids and alkalies, and that 
without evolution of gas. Diluted acetic acid does not 
alter them. They consist most probably of oxalate of 
calcium, since they effervesce actively upon addition of 
acids after strong heating. These supposed calcium- 
oxalate crystals we find, as before stated, only in 
the parenchyma of villous tissue, and only in acid 
urine. 

If the urine is strongly alkaline, and a considerable 
purulent bladder-catarrh is present, we find the necrotic 
tissue perfectly incrusted with earthy phosphates and 
ammonium urate. The patient has a distinct sensation 
as if sand had passed the urethra, and generally desires 
an examination for stone. 

On examining the soft parts of these incrusted flakes, 
we find them to be infested with bacteria, accompanied 
by homogeneous structures, groups of fine needle-formed 
crystals (crystalline phosphate of lime), and large crys- 



DISEASES OF THE URINARY APPARATUS. , 263 

tals of ammonio-magnesium phosphate and urate of am- 
monium. Sometimes in this incrusted flake we may 
find a portion of the hard groundwork of villous 
cancer. 

3. Bladder- Stone. 

If a stone is present in the bladder, we generally 
find blood in the urine after strong bodily exertion, 
which disappears after a long rest. With stone the day 
urine is consequently accompanied by more blood than 
the night urine. In this characteristic it differs from 
other forms of hematuria, in which the mixture of blood 
is constant at every evacuation. 

Bladder-stones frequently set up a bladder-catarrh. 
If the stones are small and have a smooth surface, i. e., 
stones consisting of uric acid, then we find only a blad- 
der-catarrh of the first grade. If, however, the stone is 
larger or has a rough surface (oxalate, phosphates), we 
then find a purulent bladder-catarrh of the second grade. 
The haemorrhage will be more severe, as the stone is 
rougher upon its surface. 

When there is present a smooth stone, the reaction 
of the urine is usually acid. If, however, a profuse 
purulent catarrh accompanies the stone, the reaction will 
be alkaline. 

It is important to consider whether a kidney-affection 
or pyelitis exists in complication with the bladder-stone, 
since it may be the case that, besides the stone in the 
bladder, we may also find concretions in the kidney- 
pelvis. We have then the indications of cysto-pyelitis 



264 ANALYSIS OF THE URINE. 

with, haemorrhage. (See the section on Mixed Albu- 
minuria.) 

The determination of the chemical constitution of 
the stones depends upon the chemical constituents of 
the urine ; for the crystalline and amorphous forms in 
the sediment constitute the outer layer of stone. The 
kernel in most cases consists of uric acid, since, in our 
experience, of 100 bladder-stones 90 per cent, contained 
the uric-acid kernel. 

4. Diseases of the Urethra and Prostate. 

These do not essentially change the character of the 
urine. With acute and chronic prostatitis, and also with 
hypertrophy of the prostate, occurs usually a bladder- 
catarrh of the first and second grades as a complication. 
To the acute and chronic prostatitis is added generally 
a bladder-catarrh of the first grade ; to hypertrophy of 
the prostate, corresponding to the retention of urine, 
sometimes a chronic bladder-catarrh of the first and 
sometimes of the second grade. With prostatic hyper- 
trophy of high degree, usually spermatozoa are found in 
the urine. It appears that the growing glandular tissue 
presses upon the muscular walls of the ductus ejacula- 
torii, and thereby allows the escape of the spermatic 
fluid. 

With spermatorrhoea the urine is generally neutral 
or alkaline. It becomes cloudy on heating, and the pre- 
cipitable earthy phosphates fall and dissolve upon addi- 
tion of acetic acid (Heller's bone-earths). Albumen 



DISEASES OF THE URINARY APPARATUS. , 265 

is not present. In the sediment we find, besides nu- 
merous spermatozoa, calcium -carbonate and calcium- 
phosphate crystals, and sometimes also ammonio-magne- 
sium phosphate. In the urine after the escape of semen 
we constantly find spermatozoa ; it is therefore very im- 
portant, before a diagnosis of spermatorrhoea is made, to 
ascertain whether passage of the urine brought for ex- 
amination has been immediately preceded by a pollu- 
tion or coition. 

With acute and chronic gonorrhoea we find in the 
sediment pus-corpuscles and single cylindrical epithelial 
cells from the urethra. Albumen, however, is not prov- 
able in the urine. 

Should it be doubtful whether the purulent sedi- 
ment of the urine arises from the urethra or a higher 
portion of the urinary tract, the patient should (accord- 
ing to Thompson) urinate into two vessels. The first 
half of the evacuation would contain the pus from the 
urethra, while the second portion would contain only 
the catarrhal secretion of the bladder or the kidney- 
pelvis. 

The so-called gonorrhoeal threads which almost con- 
stantly appear in the urine of gonorrhoea, even after 
normal healing, are usually catarrhal secretions from the 
ducts of the accessory glands of the urethra. Only the 
very long threads, which are seldom found, are formed 
in the urethra itself. 

Two kinds of gonorrhoeal threads may in general be 
distinguished. The first are thicker and longer, and 
have not infrequently a knob-like swelling on the end. 



266 ANALYSIS OF THE URINE. 

These arise usually from the pars prostatica urethral 
The second are thin and short, and show no knob-like 
swelling. These arise generally from Littre's glands of 
the urethra. 

Such a thread under the microscope is seen to con- 
sist of pus-corpuscles, mixed with small cylindrical epi- 
thelial cells imbedded in a homogeneous ground-sub- 
stance. (PL VI., A, 2.) 

With croup of the urethra appear small and white, 
filmy or tube-formed structures, mixed with pus and 
blood. These consist of fibrine, and are washed out by 
the stream of urine. 



ALPHABETICAL INDEX. 



A 

PAGE 

Acetone 96 

Acidity, Degree of 167 

Albumen 79, 181 

Albuminuria 207 

Alcohol 96 

Alkali-Carbonates 113 

Chlorides 68 

Phosphates 75 

Sulphates 77 

Urates 119 

Alkapton 91 

Allantoin 55, 109 

Ammonia 79 

Ammonio-Magnesium Phos- 
phate 132 

Ammonium Carbonate 109 

Urate , 121 

Amyloid Kidney 221 

B 

Bacteria 146, 147 

Bilharzia 154, 233, 244 

Biliary Acids 107 

Coloring Matters 103 

Biliprasine 103 

Bilirubine 103 

Bladder-Stone 263 

Blood, Coloring Matters of. 100 

Blood, Corpuscles of 139 



C 

PAGE 

Calcium Carbonate 133 

Phosphate 72, 73 

Oxalate 124 

Cancer Elements 152 

Villous. 256 

Casts 142, 143 

Chlorides 68 

Chlorine, Determination of 184 

Cloudiness 41 

Color 38 

Coloring Matters 59 

Vegetable 100 

Blood 100 

Biliary 103 

Concretions 155, 263 

Creatinine 66 

Determination of 178 

Cylinders 141 

Cystine 125 

Cystitis 247 

D 

Diabetes 34, 89 

Distoma 154, 244 

E 

Echinococcus 154, 233 

Epithelium 135 



268 



ALPHABETICAL INDEX. 



F 

PAGE 

Fat 109, 128 

Fibrine 82 

Fibrinuria ,-. 82, 258 

Fluorescence 41 

G 

Galacturia 129 

Globuline 88 

Glycosuria 96 

H 

Haematoidine 261 

Hematuria 234 

Haamine, Crystals of 102 

Hsemoglobine 101, 238 

Hippuric Acid 66 

Hydrobilirubine 60 

Hydruria 34, 36 

I 

Indican 59, 61 

Indigo 61 

Indol 64 

Inosite 96 

Iodine, Determination of 114 

K 

Kidneys 15 

Hyperemia of 208 

Kyesteine 151 

L 

Lactic Acid 68 

Lactosuria. 96 

Leucine 97, 127 

M 

Metallic Salts 112 

Methsemoglobine 101, 238 

Microcytes 141, 235 

Milk Sugar 96 

Mucus .„ 133 

Murexide Test 53 



N 

PAGE 

New Growths 254 

Nephritis 211 

Nitrogen, Determination of . . . . 179 

Nubecula . . 114 

O 

Oidium 150 

Oxalic Acid 67 

Oxaluric Acid 67 

Oxymandelic Acid 98 

P 

Paraglobuline 81 

Parasites 147 

Penicillium 150 

Peptone 88 

Phosphate of Magnesium 131 

Phosphates 71 

Earthy 129 

Triple 132 

Prostatitis... 264 

Pyelitis , 224 

R 
Reaction 42 

S 

Saccharomyces 149 

Salicylic Acid 114 

Sarcinse 149 

Sediment 114 

Spectrum 42 

Spermatorrhoea 264 

Spermatozoa 151, 265 

Sugar 67, 89 

Determination of 181 

Sulphates 77 

Sulphuretted Hydrogen Ill 

Sulphuric Acid 62 

Determination of 188 

T 
Tyrosine.... 97, 127 



ALPHABETICAL INDEX. 



269 



U 

PAGE 

Urates 56, 119 

Urea 45 

Determination of 168 

Uric Acid 52, 122 

Determination of 176 

Urine, Amount of 32 

Consistence of 37 

Constituents of 44 

Urinometer 33 

Urobiline 59 

Urochrome 61 



PAGE 

Uroerythrine 98 

Uroglaucine 61 

Urohsematine 61 

Urophasine 61 

Urorhodine 61 

Uroxanthine 61 

X 
Xanthine 67 

Z 
Zoogloa 149 



PU 




PLATE I.— A. 

1. Epithelium from the straight tubes of the kidney. The cylindrical cells come from 
the part nearest the papilla, the others from the higher tubules (medullary rays). 
After long standing these become spherical. — 2. Epithelium from the kidney, 
pelvis, and ureters. — 3. Epithelium of the bladder. — 4. Epithelium of the pros- 
tate. — 5. Epithelium of Cowper's glands. 

PLATE I.— B. 

1. Epithelium of the male urethra. — 2. Epithelium of the female urethra. — 3. Epithe- 
lium of Littre's glands. Plate I., A, 4 and 5, and Plate I., B, 1 and 2, all 
represent the so-called cylindrical epithelium. — 4. Vaginal epithelium. 



FLIT 




PLATE II.— A. 

Primary forms of uric-acid cr) r stals, the so-called whetstone crystals. These are 
always colored as a native precipitate, but are rendered colorless by solution 
aud reprecipitation. 

PLATE II.— B. 

Uric acid: the sediment as found in native urine; rosettes, and lamellated crystals: 
also the sharp crystals as found in pyelitis calculosa. 



PIM 




PLATE III.— A. 

1. Nitrate of urea, as seen when a drop of HN0 3 is allowed to flow under the cover-glass. 
Rhombic and hexagonal plates. — 2. Oxalate of calcium, as the native sediment 
of an acid urine. Tetragonal octahedrons and the so-called hour-glass forms. 

PLATE III.— B. 

Triple phosphates (NH 4 )M g P0 4 + 6H 2 0. The common coffin-lid crystals at the bot- 
tom of the figure, and above the fern-leaved crystals of the same, as seen when 
quickly precipitated by addition of ammonia. The crystals in the upper right- 
hand corner are crystals of phosphate of calcium, of the formulae P0 4 HC a + 
2H 2 0, from a weakly acid urine, with a tendency to become alkaline. The 
triple phosphates are found in alkaline urine. 



PUY 




PLATE IV.— A. 

Leucine and tyrosine: sediment from acute yellow atrophy of the liver, sheaves of 
tyrosine needles, and the drop-like forms of. leucine, with small double spheres 
of ammonium urate. 

PLATE IV.— B. 
The sediment of alkaline fermentation : the coffin-lid triple phosphates ; the brown 
double spheres of ammonium urate, and the amorphous tribasic calcium phos- 
phates mixed with bacteria. 



PIT 




PLA.TE V.— A. 
1. Hasrcin, or chloride of haematin, obtained by adding a grain of salt to the residue of 
a drop of urine evaporated on an object-glass, and then allowing a drop of acetic 
acid to flow under the cover. — 2. Blood-corpuscles of various forms, and a 
blood-cylinder. 

PLATE V.— B. 
Urate of sodium, the amorphous precipitate (sedimentum lateritium); also, the crys- 
tals of calcium oxalate and uric acid, together with fermentation fungi, which 
make up the sediment ot a febrile mine. 



nyi 




PLATE VI.— A. 
1. Cystine: the powder of a cystine stone dissolved in ammonia, and evaporated on 
an object-glass ; hexagonal plates, colorless. — 2. Gonorrhoeal thread, the catar- 
rhal secretion from the accessory glands of the urethra. — 3. Spermatozoa. 

PLATE VI.— B. 
Calcium carbonate, seldom found; sediment of an alkaline urine, spheres, dumb-bells, 
and granular precipitate, found usually in connection with the earthy phosphates. 



mm 




PLATE VII.— A. 
1. The massive fibrin cylinder. — 2. The granular cylinders. — 3. The hyaline cylin- 
ders. — 4. The waxy cylinders. — 5. Epithelial casts and cylinders. — 6. The uric- 
acid cylinders. 

PLATE VIL— B. 
1. The ordinary pus-corpuscles. — 2. Those with prolongations showing amoeboid 
movements. — 3. Corpuscles with their nuclei rendered distinct by adding acetic 
acid. — 4. Corpuscles as altered by chronic pyelitis. — 5. Corpuscles swollen by 
the action of carbonate of ammonium. 



TIME 




PLATE VIU.— A. 
1. Yeast fungi. — 2. Penicillum glaucum. — 3. Sarcina. — 4. Cyst of the echinococcus, 
with detached hooks. 

PLATE VIII.— B. 
I. Cancer elements, as seen in the sediment of medullary epithelial cancer of the blad- 
der. — 2. A fragment of cancerous villous tissue of seldom occurrence. 



HEALTH, 



HOW TO PROMOTE IT. 



BY RICHARD McSHERRY, M. D., 

Professor of Principles and Practice of Medicine, University of Maryland ; Member of 
American Medical Association : President of Baltimore Academy of Medicine. 



Extract from Preface. 

" Hygiene, public and private, has become, of late years, one of the most im- 
portant elements of modern civilization. It is a subject in which all mankind has 
an interest, even if it be, as it too often is, an unconscious interest. 

" The present work is addressed to the general reader, no matter what his pur- 
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tific technicalities. 

" It is offered as a contribution to a great cause, and the writer trusts that it 
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various parts of the world, and under many vicissitudes, and he has found them 
to be not vague theories, but practical truths of the greatest importance." 



CONTENTS. 
PART I.— INTRODUCTORY REMARKS. 
Hygiene the Better Part of Medicine.— The Four Divisions of Human Life: The First 
Quarter, or the First Score of Years. The Young Man ; the Young Woman. The 
Man ; the Woman. The Declining or Old Man. 

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Pace, Temperaments, and Idiosyncrasies.— Inheritance.— Habit.— Constitution.— The Air 
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vitalized House-Air.— Water.— Clothing.— Exercise or Work.— Influence of Occupation 
upon Longevity. — Limit to Labor.— The Food of Man.— Accessory Food. — Manner of 
Eating.— Tea and Coffee.— Alcohol.— Use and Abuse.— Ardent Spirits.— Wines.— Malt- 
Liquors.— Tobacco.— Chewing and Smoking should be forbidden in School.— Report 
of Naval Surgeons. 



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